Permit (20) voiDCity of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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= Request for Permit Action
l I C A p l) 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 g City Staff
(;heck(✓)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.
I 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).
65SitPermit #: ct.k.D(2. g--e) i —60 /66—
Site
e Address or Parcel#: ( 6.17 D a.w LAPP'EQ. Ioo►J_`S Gc_Q V 4
Subdivision Name: Lot #:
EXPLANATION: \,)o It �4.30_ 9.0 Re— by 165, A t✓T4,Q ác2 P tM t T
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Signature: C-. CLULE.44,..4...k..4 Date: Fj 16 1 1 4
Print Name: —Th€pspj 1 .. Lk�E i k2- fI
Refund Policy
1. The city's Community Development Director,Building()fticial or(;itt I{ngineer may authorise 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort 1
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. .A11 refunds will be returned to the original payer in the form of a check via I''S postal service.
3. Please allow 3-4 weeks for processing refund requests.
Route to Sys Admin: Date 5 i9 1I, L Route to Records: _ Date S �,, /40 By
4;404 Refund Processed: Date A/ (9- By AW Invoice Processed: Date By
Permit Canceled: Date S Zk//b d1,By Parcel Tag Added: Date By
l:A Building\Dorms\Kcyl rnnit.Action_I) 231 4. oc
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