Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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Request Permit Action I
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r I G A R I, 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- r.go
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 le<Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEAS TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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#: ot1P0/OI Li -DO0. /Y
Site Address or Parcel#: l'( 77(P 1)4 AL
Project Name: 77.--ay A r kt Ld sF S
Subdivision Name: Try v Argi Lot#: 3
EXPLANATION: Crtec sQ pGrrn, - .N ev wr Cre&*4 A el?
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Signature: Date: 0///y
Print Name: 9-etv{2..,• ltagA,i-�- 1
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b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 S s Admin: Date imm- B . Rte to 1311_Admix': Date Z/37/7/11:61.4.11111,2P7411
Refund Processed: Date g 4b91El B i1%J 4 Invoice Processed: Date B
Permit Canceled: Date 9 Zy/,y BI Parcel Tag Added: Date By
Receipt# Date Method Amount$
I:\Building\Forms\RegPemvtAction_062614.doc