Permit Support Document (16) City of Tigard • COMMUNITY DISV'i'sLUPDf h:NT DEP.Ali'1TIliN T V
■ Request for Permit Action �ip�i&
13125 SW Ilall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.govv
TO: CITY OF TIGARD
Building Division
13125 SWI lall Blvd.,Tigard, OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 'I'igardBuildingPermits@tigard-or.lmv
FROM: ❑ Owner ❑ Applicant ❑ Contractor fR) Cit\• Staff
check(V)nuc
REFUND OR Name:
INVOICE TO: B,,...."'"r
Mailing Address:
Cih
/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCI�.L/VOIll PF.RN11T APPLICATION.
RI?FUND PI?RNII'1' FP.P.S (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DL'I? (attach case fee schedule and provide explanation below).
❑ RENON"F/REPLA(-E CONTRACTOR ON PI?RN11T (do not cancel permit).
Permit #: 1n.sj;,?4 /6 —oorX13
Site .Address or Parcel #: 16 5��L- � -t
Subdivision Name: Lot #:
EXPLANATION: �,wA�ca/ �e,/y, IT i�V e�✓nr. �.-.S�r�Cv—(JOU63
_-fr-;-- of r���s� �•ry�J,9 Y-�-.
LA 7
<fz� yjv� f
Signature: )ate: 7 16'G�j1�d
Print Name:
It,fund Police
I. I he city's Conunm,ity Uceclopmcut I)iteaor.Building l)fhd;d ort ate I IIgincar Mai authorize the refund of:
•
\m fee Fee which was erroncouslc paid or Collier(&
• Ant more than go of the appIicmon or Plan mciew fee h,it an application is withdrawn or e:me,led be tort revievueffort
ha,b"r),xpcndcd.
•
\o t mor,than 80".,of file apPlIca tion or permit Fee for issued permits poor to ane in.pccoon It qot sts
_. .AII refunds\r'iII b,rerut'it,d to rhe original Paper in the It of a check via US postal service.
3. Pleas,allow 3-4 weeks For processing refund r,yuest,
Route to Scs Admin: Date Bc Route to Records: Dale / Bc
Processed: Date B- Ln-oicc Processed: Date Bc
Permit Canceled: Date / / B Parcel Tar Added: Date Bc
I.ABuilding\@rtms\R,q P,rrnirAcion-192. 14.doc