Permit Support Document (129) VoID
Cit: I. y of Tigard •• COMMUNITY DEVELOPMENT DEPARTMENT
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Request for Permit Action
TIGARD 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 ❑ Contractority Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE T 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#: VC/ 19X1/'6' C,05,53
Site Address or Parcel#: /;5 6? JJ ACi 7S L 7,TZ f/ - 4-I'
Project Name: Pe'4 / ( sS _
Subdivision Name: Lot#: '----
EXPLANATION: (r,A' /1/2,-e-,„,--t- r lV err (G'&v - J Gcvt,,,, aC1 t'-
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Signature: — Date: ///)1/4(i7 iceitAgev6 00.5 j 7
Print Name: f ,APet,
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
Route to Sys Admin: Date I d'/L By ,'.'T-- Route to Records: Date !/7 /4 B C .
.
Refund Processed: Date 4,1/47- By Invoice Processed: Date By
Permit Canceled: Date ji//f/y, By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_092314.doc