Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
■
Request for Permit Action , 5- LP
l �,;A l; � 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 •www.tigard r.g
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 Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEA TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
El INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: , 4J2 ii5--(iczct8
Site Address or Parcel#: Q?r st,,,/ `Si�r�j ft.4,,4 1
Project Name: S�/�' C,I ®®
Subdivision Name: Lot#: - -
EXPLANATION: 60,..„.41c." .,, , ltt - r %,/tee..fv,a/ 7`, a✓ vL:'.
Signature: Date: �j/��5,-
Name: 4-4,4/2•14.., /
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ONI.l
Route to S s Admin: Date 1In= B 1„�7 Route to Records: Date m® t
Refund Processed: Date MEI B Invoice Processed: _ Date B
Permit Canceled: Date ,J/s By x' f� Parcel Tag Added: Date By
I:\Building\forms\RegPermitAction_I∎231 .doc