Inspections VOID
City of Tigard COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action ///� �s 77 1
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1 ;, , 1; i) 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • . . ar - r. v
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TO: CITY OF TIGARD OCT 12 2015
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 CITY OF TIGARD
Phone- 503-718-2439 Fax: 503-598-1960 TigardBuildingPQ� c ON
FROM: [Owner ❑ Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 7y' / /j - 5 e K
Mailing Address: _ L S WM,�,,
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City/State/Zip:
art CIP- . 71-A9)f
Phone No.: ( 0 ) 3/i sr/3
PLEASE._T:_1 ACTION FOR THE ITEM(S) CHECKED (1):
(i CANCEL) ,OID PERMIT APPLICATION.
11 'I_ - Il D 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#: /oL/t7 /.5- 00 33/
Site Address o Parcel#: p��►iiiKt aMTIg/1�rf.
Pro'e ► - - 9 '3O Jed ■/e4oadlaS
Subdivision Name: 779qy'1j'1 QF- t#:
EXPLANATION:
II /Signature: /Ae, �/a .�//N //// Date:
Print Na " ,/ . , �I L. ., %/
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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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 // / NI B /';-- Route to Records: Date " MACAlerir,IMII
Refund Processed: Date By ,fi7 Invoice Processed: Date By
Permit Canceled: Date VG s" By 4%', 'arcel Tag Added: Date By
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I:\Building\Forms\RegPeutAction_0 231 .doe