Permit •
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT volp
Request for Permit Action °/'y�'y
T I G A RD 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •www.tigard-or.gov
1 U: 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 Er City Staff
Check(1)one
REFUND OR Name: d/fr
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
�►�� CANCE OID PERMIT APPLICATION.
r - - II 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#: c6w4—•o20/3 — OD/(p /
Site Address or Parcel#: 6'26 3 At) aseE,d4,€.4
Project Name: 6(,t6LAMA/
Subdivision Name: //r� Lot#:
EXPLANATION: /3L ( 46�i �JTt /� Atio2o/3-cool 4/6
/04'5 n/o //JCZE. //■-) ig f.gc.)f2. Ebta 's .PF0_ t Xr i.€ 4 -771fek
Ci.` I
Signature: 0_0, Date: /4/7/�f
Print Name: e46/f /Ia4i 144 /./
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ON].)
Route to S s Admit': Date /0 ®opw2 Route to Records: Date , A=I By ,_i 'F'
Refund Processed: Date B Invoice Processed: Date By
Permit Canceled: Date ohViye B;`� . Parcel Tag Added: Date By
1:\Building\Forms\RegPermit.\ction 192',1-(Joc