Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT / 1 , :
a Re uest for Permit Action a s
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I ;(,A p D 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 K City Staff
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REFUND OR Name:
INVOICE TO: (Business or Individual) /11-
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 #: PLLY1 oto l (p —n co 3 7
Site Address or Parcel #: I Xe?f /bite 6/ i1 dr
Subdivision Name: Lot #:
XPLANATION: P . •. 1,1 ,Nt�i ,Akd , -AA , rev
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Signature: I �C t sate: I1a41/b
Print Name: L EA,61 f A�•Prrv\-511-b
Refund Policy
1. The city's Community Development Director,Building Official or Cite 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 LIS postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to S's Admin: Dal- t. AT (-Co B\ ''r Route to Records: Date /'/ By a;r.
Refund Processed: Date 4- By ,lea Invoice Processed: Date By
Permit Canceled: DateS/o B'„ - . Parcel Tag Added: _ Date By
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