Permit Support Document (167) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 0
=III Request for Permit Action
4W-
TIC A R C) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439th sv.tig d o `tig V
TO: CITY OF TIGARD i'. '
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 3
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildi lgPeinutsgtigard-or.gov
FROM: ❑ Owner ❑ Applicant A Contractor ❑ City Staff
Check(✓)one
REFUND OR Name: 1t/ )
INVOICE TO: (Business or Individual) V k, E76, ��' 111 _
Mailing Address: e..– ( r Li /%1;E-",,C l 57City/State/Zip: U /16,4UE 4 9e574"/
Phone No.: 56 3 5- 047tyi
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
4 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#: a /`076/0.--06'3
Site Address or Parcel#: /063/ SL..) CASC.61-6, ?III
l reek - i og '7y
Subdivision Name: "" —. Lot#: '.."--`
EXPLANATION: V y°f�-t /` 1.1(7a ,en- 7,017- - A)6? T
pxi, 2-'91T2,4c f-'67g1-1ir
Signature: 7/:
//, ? Date: 7` -z --- - ay.e
Print Name: ie L. ,e,72 a 4--
Refund
oRefund 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 7 /4' By g.;,. Route to Records: Date g /6 /A, By
Refund Processed: Date tt/1j4 By.sejtV Invoice Processed: Date By
Permit Canceled: Date '?//41/1., By /4r Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_O 2314. oc