Permit RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action AUG 3 2015
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13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tl�t0t.8o iliVi
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TO: CITY OF TIGARD 1 1
Building Division �5 4/"..9
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov
FROM: 'Owner El Applicant ❑ Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 4E-x, S /72„x
Mailing Address: /00 at/7 ��7
City/State/Zip: /41f/L oA/41-76i73 70
Phone No.: sy/ ',6 O 66 302,
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#: S'GtW 2,20/5'
--Q oe 2 c,
Site Address or Parcel #: 20 fro <Crc, ,j/2 L A J7-T 7/0
Project Name: .6 EQ //yam /(74E-",L4 7771 (7
Subdivision Name: Lot #:
EXPLANATION: re.677.4 tz./JCL S Tp/tEe..f 02(G rtirg-c_. Cc`fE�c�
/2 T V E7 SAME c 9 y 9
tc-sct.cL7 E2 /Al/ E -c, 0/4E-6 r7 }
Signature: t-�^� - '1°1' Date: ,`3 V2.-0 IS-
Print
Name: Re.)( SNn�Co jev I
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 LASE ONLY
Route to S s Admin: Date B Route to Records: Date fJ j B -tis(-
Refund Processed: Date d" 3 / . By 1. nvoice Processed: Date By
Permit Canceled: Dated=/ . 5 By a Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_69231 .doc