SGN2016-00072 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action ///c/fc, "di*
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 ❑ Contractor City Staff
Check(1)on,
REFUND OR Name:
INVOICE TO: (Business or Individual) o(- Ti �,,�� M;,A.k_ L U-e c
Mailing Address:
City/State/Zip:
Phone No.: 11`o - ,Z 5 Cj 3
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#: E 6 N 2.01 (.0 — O OO-2__
Site Address or Parcel #:
Subdivision Name: Lot #:
EXPLANATION: Vol'4_ vn•,-t , �" -2' f--r v I
Signature: Date: 7
Print Name: N/“.-) ; (-i, 6110 dttGA1
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 47 /6, /fr, By v
Refund Processed: Date AUX By lInvoice Processed: Date By
Permit Canceled: Date Via, By 41-vi Parcel Tag Added: Date By
I:\Building\Forms\Reg Permi tAction_0923]A.doc-