Permit I
1 II
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
■ Request for Permit Action �/s 9 s -„ r
I I L;,\R ) 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: El Owner ❑ Applicant El Contractor El-tr y 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 (✓):
❑ 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#: 611 Pg0 15 —O t i 5
Site Address or Parcel#: //7""l s— se.✓ 6rx Vbi /2.04
Project Name: G('Y e Q 0i.i Ply,
Subdivision Name: Lot#: ---
EXPLANATION: C � ,rm►1- ,W ea-e--,r, 8IP , .669 .17) b-r
- ! /7&. /ice ,Br ( le- 2orws
Signature: �_` Date: 1'
Print Name: ' L
//•
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ONLY
Route to S s Admin: Date MEM B EP Route to Records: Date ,,I�l�MIii t+iaal.
Refund Processed: Date A/Z=11 B r'�/I Invoice Processed: Date B
Permit Canceled: Date _ B gm Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1 231'.doc