Permit I
City COMMUNITY o f Tigard •g Y DEVELOPMENT DEPARTME
ReRequest Permit Action Aug j 2C=
q
TIC A R I., 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • w c d L
TO: CITY OF TIGARD I D
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223 1//�d
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor gi City Staff
(check one)
REFUND OR Name: I/
INVOICE TO: (Business or Individual) �/ /�
Mailing Address: '
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
ECANCEL/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).
El REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: El-20,10/V- o l 'D-
Site Address or Parcel#: /1/6V0 5t.3 l f 7 �L
Project Name: /JjJs',t) ASad
Subdivision Name: n Lot #: / //,/
EXPLANATION: (f/9-rpr) LvQoeJE PEQ/'f I T-1yi _ • �� &Lo1p/Y-u'�'/c ',
Signature: eiket,IbUta-ii Date: c%% /�
Print Name: E 4D/9M 5 k
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b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
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 n 14( Ric to Bldg Admin: Date f /7' By o ' _
Refund Processed: Date /I/ Invoice Processed: Date By
Permit Canceled: Date // /y B Parcel Tag Added: Date By
Receipt# Date Method Amount$
I:\Building\Forms\RegPem itAction_062614.doc