Permit Support Document V 0 I
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ....3/4,k5"
III ■ Request for Permit Action
r I(;A 1; 1 , 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 TigardBuildingPertnits @tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ity 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 (1):
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#: //)'1 C-k IC--ao/bc-
Site Address or Parcel#: 71/Q 34.4 L?eue/ / S
Project Name: & 1r-'wi/ee-4,- 0A)
Subdivision Name: Lot#: '
EXPLANATION: C fr,?,.,j 1"-i- 4,1 a /t s t Nda4 A Qc/ 1n 2 ,,`cv.1
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Signature: ! d��/i5�-
Print Name: ��'
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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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 tISE ONL\
Route to S s Admin: Date B ' `'.\ Route to Records: Date, ®® B,iizr.
Refund Processed: Date ,(/4- B a 47 Invoice Processed: Date By
Permit Canceled: Date -/ . s By e", Parcel Tag Added: Date By
I:\Building\Forms\RegPemvtAction_09231 .doc