CUP2014-00002 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
171"1
Request Permit Action , I ,,
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tiggrd-or.gov
T O: 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):
CANCEL OID PERMIT APPLICATION.
R i 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#: W P ZO l 4-0000 2-
Site Address or Parcel#: IDLL5 s5 J J Cavt-katou nii L- I
Project Name: ('xhve pry .J1 --leico I
Subdivision Name: Lot#:
EXPLANATION: ir1Yflnec4 1 - CUP jS hod r ec,ssav9. -
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Signature: J ` p U/14 Date: ID( 2 j j 14
Print Name: Mncs- V\ac
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b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 800 o of the land use application fee for issued permits.
d) not more than 800(i of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80°i 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.
FOR OFFICE USL ON I.A
Rte to Sys Admin: Date By Rte to Admin: Date /D/y//y By ,
Refund Processed: Date Atin By„e!/i Invoice Processed: Date By
Permit Canceled: Date /B/Z/jy By off, -arcel Tag Added: Date By
Receipt# Date J Me od Amount$
I:\Building\Forms\ReyPemvtAction.doc Rev 05/25/2012