Permit •
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Jj
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Request for Permit Action PS <t2W-
i , 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 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#: 61,70/5---ej3ct
Site Address or Parcel#: X411/5 51,i /irta,/Z,i4,,r /A,/
Project Name: /ee,-Of
Subdivision Name: ,,-- . Lot#: —
EXPLANATION: �e,,,,,,f ,h, G`,ry, - 8 ,I,c &' ha- er /yV`T
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N ".-1'7` ,hr7,Za5.--041),30
Signature: Date: o2/1 -1∎$'
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
I. • 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 Sys Admin: Date - oti is— By/j.7 Route to Records: Date 3 2./L By I—•
Refund Processed: Date B .02 Invoice Processed: Date B
Permit Canceled: Date .a,67T1IN B 6P`2111 Parcel Ta:Added: Date B
I:\Building\Forms\RegPermitAction_1 231 .doc