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Permit Support Document (168) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0 1 0 Ilig . Request for Permit Action VO, 4tft--- T I G A R 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 ity Staff Check(✓)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. D 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#: Et C i 6 -on 5q(0 Site Address or Parcel#: /Y/63 //s*' (9-. Subdivision Name: //j4V /? {�/.�,}c 1 Zot /5— Lot#: EXPLANATION: (-> mrce,d �-. ,.,1+ ryv ev-r we CI-C- ii, ...44 1 cW t-'6-le. 4' - 9 9e4te-v,i. Lre-gotta 'k' t77 Signature: .,.. � .c ,�'� Date: `7/o �/t1 k, Print Name: re-ht..z-6...._, if- , 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. Route to Sys Admin: Date '7 . G 6 By K, Route to Records: Date c�//y,/' By,h--- Refund Processed: Date By` Invoice Processed: Date f By Permit Canceled: Date V' laf(,,,, B arcel Tag Added: Date By I:\Building\Forms\RegPermitAction_0923'14.doc