ZCA2011-00002 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 '
N �
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: 503-598-1960 TigardBuildingPermits@dgard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
Check(✓)one
REFUND OR Name: N/A
INVOICE TO: (Business or Individual)
Mailing Address:
E
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
® 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#: ZCA2011-00002
Site Address or Parcel#: 14031 SW Alpine Crest Way
Project Name: Otis Annexation
Subdivision Name: N/A Lot#: N/A
EXPLANATION: The applicant chose to not pursue the annexation in 2011,but
re-submitted the application in 2013. See ZCA2013-00003. Please void ZCA2010-00002.
Signature: O CDate: 7/6/15
Print Name: Cheryl Caines
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
• ' OFFICE USE ONLY
Route to Sys Admin: Date B1% Route to Records: I Date
Refund Processed: Date Wlf By4WI I Invoice Processed: Date B
Permit Canceled: Date 7A& B Parcel Tag Added: Date I B
I:\Building\Forms\RegPemiitAction_0 23 4.doc