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Permit
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMVT 0 1 0 Request for Permit Action /Z/Y � T I G A R D 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 try Staff Check(1)■nn REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): [ CANCEL/VOID PERMIT APPLICATION. U REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit#: 4g4P iJ'J- Cr rr Site Address or Parcel #: /OS'� ) AA-4,7A Qom,1,ed j g Project Name: F,jV24lce_ 40 Subdivision Name: Lot#: ~� EXPLANATION: Cre,p y , /%"e-e- ' 7fr be. a "45— y- ?gr- aiv o,1 72z/tie. We—f_A,1 �M.,` /17 67 O/`l .r'&-//_�- Signature: Date: /o2—j/t, Print Name: 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 I.1 Route to S's Admin: Date 47,J B ; , Route to Records: Date Z©�•'� ._, iam Refund Processed: Date , ' By 4,421 Invoice Processed: Date By Permit Canceled: Date/_ / B1,„2,7 Parcel Ta Added: Date B g By I•\Bui1 in Forms Re PermitA ion f 231 .doc t d g\ \ � ct _