SGN2017-00049 City of Tigard • COMMUNITY DEVELOPMIIiNT DEPARTMENV I 0
111q
Re uest for Permit Action -c' 2410
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: El Owner ❑ Applicant ❑ Contractor ® City Staff
Check(✓)one
REFUND OR Name: N/A
INVOICE TO: (Business or Individual)
Mailing Address: N/A
City/State/Zip: N/A
Phone No.: N/A
PL E_TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCE OID PERMIT APPLICATION.
El 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 #: SGN2017-00049
Site Address or Parcel#: 12860 SW Pacific Highway
Project Name: Jiffy Lube
Subdivision Name: N/A Lot#: N/A
EXPLANATION: Applicant never paid application fee, and now requests to void this permit.
Date: 5/10/17
Signature: �__�
Print Name: Lina Smith
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ,s�o /7 By,
Refund Processed: Date A///9- By .1 A Invoice Processed: Date By
Permit Canceled: Date g2,6//7 By / Parcel Tag Added: Date By
I:\Building\Forms\ReyPemitAction_ 9231 .doc
f...,t E iv
(n ', Eki,„,,,
E®
City of Tigard /2i//79- MAY 0 9 2017
11111 a
SCOT
COMMUNITY DFVF.L(.)PMENT D1 PART\11:\T'
'
Temporary Sign Permit Applcaticw CITY
OF TIGARD
TIGARD /ENGINE RING
: ..,.. __ ,..�� _ • �.�H_,,_.. _ ma _.
SIGN LOCATION
12860 SW Pacific HwySuite #: REQUIRED
T�
Address: ELEMENTS
City/state: Tigard,OR Zip: 97223 I74, Size information type and size
Tenant or business: Jiffy Lube dimensions
❑ Application Fee
Property owner: IA
Property owner signature/
Address: De) 5 ,C).1�G J\v� , written authorization
City/state: Qt9rI'lcirt.c , 01- Zip: Cl. 7Z-3.2NOTES:
Phone: Email: CD CCT t...--tW 1.-t doItto�, • Applications will not be accepted
Contact name: -r✓'o y LT Ct ii,e without all required submittal elements.
• Temporary Signs I8.780.10(1
APPLICANT • Balloon Signs 18.-80.10()
Name: Doorknob Ventures LLC dba Jiffy Lube
Address: 1805 NE Sandy Blvd FOR STAFF USE ONLY ;�
City/state: Portland,OR Zip: 97232 � Gl�_C,C�LJ�g
Phone:(503) 582-0505 Email: Ap@doork.nb.com
Case No.: a
Contact name: Pei M ; or lAci i I Approved and issued:
By: Iaa c:
SIGN INFORMATION (Check all that apply) Permit fee: �
3
❑ Balloon Map/TL#: Z/D2 01%0
Install date: (Valid for 10 days) Zoning: c2-q
❑ Lawn Sign (Including A-frames) Total sign area: �
�`
I Install date: (Valid for 31)days)
1:\CURYLNV+1arieri1Wna Ute A.nptica6vns Rev. 2J22l2016
al Banner
Install date: 05/05/2017 (Valid for 31)days)
0 Other:
Sign dimensions: 8'X 3' Sign arca: 24' (scj.ft.)
{ Materials: Vinyl
Direction wall faces(circle one: N E \X' NE NW SE SW
Dc2-v-ev; °,01 0-9- C/ C' Y117
Ajlicant's i ,- Print name Date
-Tim (�6t P ova t� 5` S 1 ) 7
'
Owner �
, Pont n,me
'lite
r
'7774i-.Tij;a 5»S\X'Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or;goy • 503-718-2421 • Page 1 of 1