TUP2016-00004 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0
1
11111
Request for Permit Action ;.a
q a/25
I I(,n p i) 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 TigardBuildingPermi @tigard-or.gov
FROM: n Owner ❑ Applicant ❑ Contractor City Staff
Check(✓)one
REFUND OR Name: I
INVOICE TO: (Business or Individual) O
Mailing Address:
City/State/Zip:
Phone No.:
PL ASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
j
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 #: 1 U P 2 D 16- 0000q
Site Address or Parcel #: 9q26 SW Mord oc k St.
_i2i:i_ %i:,;'I,.)(
Subdivision Name: 1%A-dock Skree+ Pal's►'I'I o n Lot #:
EXPLANATION: no `T\J p f 9pti reA , Cr eak'e, in eAr+ra)
Signature:
Date: 2 2 1 I 6
Print Name: Ti Le,hrbach
Refund Policy
1. The city's Community Development Director,Building Official or City Ingineer 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• Not more than 80°%of the application or plan review fee when an application is withdrawn or canceled before review effort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. .\ll refunds will be returned to the original paver in the form of a check via VS postal service.
3. Please allow 3-4 weeks for processing refund requests.
Route to Sys Admin: Date By Route to Records: Date .2. /(o BA
Refund Processed: Date /✓!j')- By Invoice Processed: _ Date By
Permit Canceled: Date,,,7/2X//4„ By Parcel Tag Added: Date By
I:A Building\Forms\RegPcrmit:Action_d9231 doc