SGN2016-00073 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
illal q = Request for Permit Action 174.,74.,
i ;t;A I: 11 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: El Owner ❑ Applicant (l Contractor A City Staff
Check(✓)one
REFUND OR Name: --11( "Q
,
INVOICE TO: (Business or Individual) I 'n ^ r vl ti OP 11 Ti r- M i 1_Uec,k
�J 1
Mailing Address:
City/State/Zip:
Phone No.: -1 )3 - 2,C Gl ?
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL/VOID PERMIT APPLICATION.
p REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
El REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: SN 2.01 (0 _ 0 0073
Site Address or Parcel#:
Subdivision Name: Lot#:
EXPLANATION: V Di A P2.(m ( k , NU lair (tL I Y p v ILL ck,
Sip, p-exw► i t-- .
Signature: Ai Date: 7 / 2 7 / 1 i'
Print Name: 1\4o n i (--, (3 Jo ol.e c,...k-A__
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 /4 l6 By rJ .
Refund Processed: Date /(/ /i- By, " Invoice Processed: Date By
Permit Canceled: Date /f 4/4, By arcel Tag Added: Date P_Y
I:\Building\Foams\RegPermitAction_0 231 .doc