SGN2014-00083 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V
•
Request Permit Action / /
y Irr
TIGARD 13125 SW Hall Blvd. • Tigard. Oregon 97223 • 503.718.2439 • www.tilzard-or.fov
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
tigard-or.gov
FROM: El 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 (✓):
® CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
n REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: SGN2014-00083
Site Address or Parcel #: 7148 SW Gonzaga
Project Name: The Adrienne
Subdivision Name: Lot#:
EXPLANATION: Based on the error message, I did not realize the permits had been
created so I started over. These permits are not needed because the signs were issued through
permits : _. k SGN�2+014-00088.
Signature: (,'L4- t_C '- ' Date: 7/1/14
Cheryl Gaines
Print Name:
Refund Policy.
I. 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b) not more than 811°u of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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"o of the land use application fee for issued permits.
d) not more than 81° of the building plan review fcc when an application is canceled before any plan review effort has been expended.
c) not more than 80°o of the building permit fee for issued permits prior to any inspection requests.
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 Sys Admin: Date By Rte to$Idg-Admin: Date 7/L 0 y By,f
Refund Processed: Date Ai 4- By 41 Invoice Processed: Date By
Permit Canceled: Date 7 70 if By Parcel Tag Added: Date By
Receipt# Date Method Amount$
I:\Building\forms\RcgPermitaction_t162614.doc