Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0
114
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Request for Permit Action ,?/2.5A, k-4g----
T ,c,A it i 1 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@tigard-or.gov
FROM: ❑ Owner ❑ Applicant n Contractorits Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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 #: fe4,RO/62--`Oft)S-67
Site
Address or Parcel #: /,30,52 S� G "..,c /
/f;le &le 92,22-)
Subdivision Name: ,S�'7).,,,,,, le:4C - Lot #: /4'c
EXPLANATION:
P� yam.,t , ,, e����. ezi, '/-
-A9G" '' /79ST /ye.1-d , ,t /hSJ'ad/ - c12r
Signature: Date: 4,2/7A
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Print Name: . aa/i.�/ �� ,—.`,
Refund Policy
1. The city's Community Development Director,Building Official or Cite 1?ngineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 800/o of the application or plan review fee when an application is withdrawn or canceled before review effort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 PS postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to Sys Admin: Date Z /f/L By 4 Route to Records: Date c2,5' /4 By ii
Refund Processed: Date /.t By " Invoice Processed: Date By
Permit Canceled: Date .2/25/4 By ,1-..' , Parcel Tag Added: Date By
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