Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEN
'PI Request Permit Action • 0 I ,
q 7/2y/,y 4/1
TI G A R I) 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503.718.2439 • www.tiga d-or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor lig City Staff
(check one)
REFUND OR Name: 'I'
INVOICE TO: (Business or Individual) N/A
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
.E. 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#: cps o2 pl L/DO 1A/
Site Address or Parcel#: , O 'S 6w /1#44...e_ ZLI/O =`"/, )
Project Name: ,4/ j z_L ,c}n,(ij S 151 )gr5 /-42
Subdivision Name: Lot#:
EXPLANATION: 4pHir- @Q ,4 7-Et] t 0 Ekibi . 1 624-1,7- Tv
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Co Asraft e T ' •
Signature: _ 0 /.�A,` _ Date: 7/r4//V
Print Name: I. J t 6/fj I f ,Q• Mpee}MS A/
Refund Policy
1. The Community Development 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b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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%of the land use application fee for issued permits.
d) not more than 80%of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80%of the building permit fee for issued permits prior to any inspection requests. 1
2. All refunds will be returned to the original payer in the form of a check. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Rte to S s Admin: Date rffli ...✓ Rte to Bid. Admin: Date 2 AffILTZfrr
Refund Processed: Date ' By I AA Invoice Processed: Date By
Permit Canceled: Date 7/yy/i y By ;,-- Parcel Tag Added: Date By
Receipt# Date Me od Amount$
I:\Building\Forms\RegPerm itAction_062614.doc