Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT °
s ReNquest uest for Permit Action a/Zy/is
r i<;A R 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 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name: _
INVOICE TO: (Business or Individual) , 5 C
Mailing Address: 52 Tj E,A DOSD S 1 - LI I
City/State/Zip: LA QS o a OR cr7 035
Phone No.: 5'03 - Co 5 y7 - L( 0 vZ
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#: pC4V1, GQDJ/
Site Address or Parcel#: " iA PsN Tt GAP_O 1 OR
Project Name: As tAw 'C S-• E
Subdivision Name: Lot#: 9
EXPLANATION: C A N k p L A NIS s'ci.?.e,7a/S`-CJC1/
Signature: C� �- _ Date: 111 I 5
Print Name: LE G Ll ( A J
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
Route to Sys Admin: Date B Route to Records: Date /1 / /f B
Refund Processed: Date N f}- By ;f Invoice Processed: Date By
Permit Canceled: Date /2/Z Le/'s By i� arcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_09 314.doc