VAR2013-00025 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT, /
1� o I
Request Permit Action 3/zsiy
TIGARD I I ` SW Hall Blvd. • Tigard. Oregon 97223 • 503.718.2439 • www.tigard-or.gov
'I O: CITY OF TIGARD
Building Division Services Supervisor
13125 SW I lall Blvd.,Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
. CANCEL/VOID PERMIT APPLICATION.
n REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
n REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: S Qj20 l 3 -CC007 a v4 \f f c 2 13-00025
Site Address or Parcel #: Di(.0(1) SO)
Project Name: ql2A.Cac-NIO
Subdivision Name: Lot #:
EXPLANATION: WrnntJ- N}- odaa pi f "t1r11S -1m - Nov t1" IS A-
eC Et - (' 13X01 4 -6000 oZ- .
Signature: J 16)4 Date:
Print Name: nes KOV\G'LC
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was emneously paid or collected.
b) not more than 80"o of the land use application fee when an application is withdrawn or canceled beti,re any review effort has been expended.
c) not more than 80°°of the land use application fee for issued permits.
d) not more than 84W o of the building plan review fee when an application is canceled before any plan review effort has been expended.
c) not more than 81)".of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will lx returned to the original Payer in the same methnd in si hieh r ivment,r.1,received. Please allow 2-4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date , Rte tot 1 ldnun: Date 3 Z5
Refund Processed: Date/1/161- B• .44 Invoice Processed: Date By
Permit Canceled: Date 3/ZS//y By /14 _ Parcel Tag Added: lute _ By
Receipt# Date Method Amount$
1:1Building\Forms\RiVermitAction.doc Rev 415/25/21)12