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ZON2014-00001
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 111 V r Request Permit Action %s//y TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-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 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): al CANCEL/VOID PERMIT APPLICATION. i HERMIT 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#: ao/y_000n1 Site Address or Parcel#: Sa0D S cc, s-hrog_t Project Name: A yyp( D ikipAYtrS Subdivision Name: Lot#: EXPLANATION: CPA- -K Ylow Gt 2niJ —W'fbYlp, Fenn: 4- ( k4. 77Zmvs e. s/P4yMLwr /- i f 7 J2O/y-0000/ 70 e,9"c:Q0/1/— 0000 Signature: ifl a t :41 14" ;e: e• 11 if. I y Print Name: P/ fy 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 b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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°o of the land use application fee for issued permits. d) not more than 80W o of the building plan review fee when an application is canceled before any plan review effort has been expended. e) not more than 80",'0 of the building permit fee for issued permits 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. I ( (I■ ul i 1(.1, 1 '1 O Rte to S s Admin: Date B Rte to '••-• Admin: Date , © r' B jt'ia ,n-btNy --..8.ef u Processed: Date .'ByAri- B' _,0//-Al Invoice Processed: Date B Permit Canceled: Date '/2 /y B Si. Parcel Tag Added: Date By Receipt# Date i ethod Amount$ 1:\Building\Forms\RcgPermitAction.doc Rev 05/25/2012