Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 D
1 •
11 Request for Permit Action Ca//y/iy edi*--
,, 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
•
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
(►2. CANC VOID PERMIT APPLICATION.
•a ND 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#: 6I,0Q.0qO/O - 00/54/
Site Address or Parcel#: 9(5 a4 ,/f
Project Name: !,,4 M
Subdivision Name: Lot#:
nn
EXPLANATION: lip 1� �i 5 6'E,P_/y/r f3 5 (...Q,„,04., 1434 5
44.- RE/3--/-}C f/`-/E ti 7 u 7u2 5/ 14 5 /do EDe.t /, 4-S c .
Signature: Date: /% //c1
Print Name: ( t,,/s/ /(
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 800/s of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or 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 via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to Sys Admire: Date/0Ar Elfve i Route to Records: ,4IArAl B
Refund Processed: Date it/ /r By,C4�� Invoice Processed: Date By
Permit Canceled: Date/o//ry B �''r" arcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_O 231'4.doc