SDR2016-00012 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V
14 I. Request for Permit Action ///7)9.,
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: p Owner ❑ Applicant ❑ Contractor jv City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) C 0
Mailing Address: M 0 rl 1 CC'1 ) 1(00U Gvc / 1 312.s s w 1-tr 1 1
City/State/Zip: -Ft- 0 2Z, Q ( G}7 3 L3J
Phone No.: S03 1 - 2421
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
, ] CANCEL/VOID PERMIT APPLICATION.
U 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#: S p P-ZO I (O — 0001 -2_
Site Address or Parcel#: 18,0 0 0 Sri //4L -
Project Name: 2 1 7 T19 ctr-al .0179 r
Subdivision Name: Lot #:
EXPLANATION: C rse-0 -e--k f r1 eve r p-e-L e-1- - Perrh
Signature: (V1 (0/\"---, Date: IC/2-7 / j (D
Print Name: M e n j C ct /31'I o 0L2 CAA..&
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: Date 9/7 / , By I ` ✓
Refund Processed: Date N/ff By Am Invoice Processed: Date , By
Permit Canceled: Date ///7//(, By t!-•. Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_09231 .doc
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
No Re uest for Permit Action
Request
• , \•t •) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov /21Z5P.P
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 [City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
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 #: 51) 2O( 6 !d am/L
Site Address or Parcel#: /i %d o /1630 i/g6 >w/(,1Gf 11/479(
Subdivision Name: N Lot #:
EXPLANATION: 5 bit ii),0 7 Deer U/(; G U/' /<
;,1 S - se U t lk 42--e)1 — P -
Siaire:
•Ct ,„Alf, Date: L=l Z -` t
Print Name:
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 800/s 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 By Route to Records: Date/VPV/6 _ By 7
Refund Processed: Date A//A- By4/ Invoice Processed: Date By
Permit Canceled: Date /7i 23//(, By4 Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_092314.doc