Permit Support Document (12) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEN
Request for q o Permit Action oh7 ..
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 cgt. City Staff
Check(i)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
4_ 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#: &4G 0919/7 - Q(j t 31
Site Address or Parcel#: 440 /406' Da..
Project Name: L ��
Subdivision Name: Lot#:
EXPLANATION: CZE ft 7) -s <1.0,24,0 Co Pe.,2Hi r"
I7–Cr4 2-
Signature: ( �0--�� Date: //5/7
Print Name: &-6 i g ,,4"D,¢rti 5/4 `
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 le /6 7 ft Route to Records: Date 7 6 /`7 By —
Refund Processed: Date/ By iriir Invoice Processed: Date By
Permit Canceled: Date 7/i,//' By c"-: Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_ 9231 .doc