Correspondence 2014-06-11 10:54 Wells Fargo Bank, NA 5038863344 >> 5035981960 P 1/2
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
" Request Permit Action
I-f,i A l•' t) 13125 SW Hall Blvd. •Tigard, Oregon 97223 •503.718.2439• ww d El'
TO: CITY OF TIGARD
Building Division Services Supervisor JUN 1 1 2014
13125 SW Hall Blvd.,Ti . R-992Q3
Phone: 503.718.2430 lax: 503.598.1960 www.tigard-or.gov CITY OF TIGARD
FROM: Owner ❑ Applicant ❑ Contractor DIVISION
(check one)
REFUND OR Name:
INVOICE TO: (Buvincw or Individual) d/73--
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
n CANCEL/VOID PERMIT APPLICATION.
• REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: 1'76 r•90/ll 000/
Site Address or Parcel#: /0 76-7 'tom: /J- /A Tip'•
Project Name: ^ 7 OficST0
Subdivision Name: Lot#:
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Signature: Date:
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Print Name; (4U S S L Tc7s 1A
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80°/n of the land use application fee for issued permits.
d) not more than 8U%of the building plan review fee when an application is canceled before any plan review effort has been expanded.
u) not mule than 80%of the building permit fee for issued pennies prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2-4 weeks for processing refunds.
Rte to Sys Admin: Date By Rte to Bldg Admin: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date By Parcel Tag Added: Date By
Receipt# Date Method Amount$
I:\Huilding\Itorms\1tcgPcrnitAetion.doc Rev 05/25/ 12 aC.y
04.9.11
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