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Permit 1111 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT I 1 i Request for Permit Action // - 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: 5 3-598-1960 TigardBuildingPermits @tigard-or.gov FROM: ❑ Owner Applicant ❑ Contractor ❑ City Staff Check(1)one REFUND OR Name: INVOICE TO: (Business or Individual) S 1 �`-� 2 rid? (40 N Mailing Address: -(23o C74(eutood 94 N City/State/Zip: t4 0.5 r,✓ d i (fig 9103S- Phone No.: 503 37.?577 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): CANCEL/VOID PERMIT APPLICATION. RFFi� ERMIT FEES (attach copy of original receipt and provide explanation below). INVOICE F R FEES DUE (attach case fee schedule and provide • - • ;o • ,- •w . E/REPLACE CONTRACTOR ON PERMIT (do n• cancel permit). Permit #: M 5T 2'01 S--00/35" =if i( 4 j--eM 0 9/ Site Address or Parcel#: V Project Name: Sjo"f-(rlv ti■ I./j Ll f Subdivision Name: ✓ Lot#: EXPLANATION: 5 ub '�/ 5 f,eC. plg✓l G�✓(c Sold a dt e -.eye f 5 . �(91r �� fuils Sc C / c7 /S DD/SV��i�,� is�0/o3 . Signature: mil' Date: ``'Zv / Print Name: 6h� P e -uC C ` 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 ONLY Route to S s Admin: Date B Route to Records: Date AV© B Refund Processed: Date it43111.1 Invoice Processed: Date +AIMI ZFAIII Permit Canceled: Date ` �r�/s By ' . -Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_O 2314.doc