Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
4" Request for Permit Action V 0 ' Q
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T I G A R 8/3/45.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: El Owner ❑ Applicant El Contractor City 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):
1 CANCEL/VOID PERMIT APPLICATION.
El REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
El REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: , ( p70!5--.Ups/
Site Address or Parcel #: 4:2:20q sc.,) 5?wive t 4.A/
Project Name: Gj�/ve;(,�
Subdivision Name: Lot#:
EXPLANATION: ( / J .,,j,,,, ,^/ ti / 6-r
% 4/e,./ 7 Ai )2`'O/ c=on tio .
Signature: . Date: 7/ //
Print Name: Le o
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• Not more than 800/s of the application or plan review fee when an application is withdrawn or canceled before review effort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 MUNI B ! _ , Route to Records: Date rAMIIM B
Refund Processed: Date 41 By ,r-" Invoice Processed: Date By
Permit Canceled: Date ,r 3 4.d S By .lam'• Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_I 23 oc
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