Permit (22) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEN 0 I
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= Request for Permit 57z6/4„
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-, ,,;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 n Contractor [Staff
(:heck(i)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
Cite/State/lip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
PERMIT APPLICATION.
? .-- CANCEL/VOID
11REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPT...-ACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: j(,Gp'0/G—CV itA/
Site Address or Parcel #: / S „yeii $J' 7jT.
/,:74-...?,( t cy. 9773
Subdivision Name: -INO.... 'mmir• Lot #: —
EXPLANATOION: ( - f ��,.►r t i'/\/ �iz�l 1 (_1� S/j/e.2.�(��,/
Signature: fr L/� _— _ Date: *-3�1�
Print Name: e.A — ✓'
Refund Policy
1. The city's Community Development Director,Building(>fficial or City I?ngineer 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 pacer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
Route to Sys Admin: _ Date s- /4. By j Route to Records: Dat /. /4, B}
Refund Processed: Date // B.,it Invoice Processed: Date By
Permit Canceled: Date S/20 /4, B or, Parcel Tag Added: Date By
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