SGN2017-00062 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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Request forPermitAction X 1 !0
7/647
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13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.ti and-or. g`'
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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 tt City Staff
Check(/)one
REFUND OR Name:
INVOICE TO: (Business or Individual) j,? ( c U Q k\O d QCJ1 c)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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#: S C,f1civ20 (7 — 0 00&
Site Address or Parcel#: l 2Ca 2 S S‘") Pae
Project Name:
Subdivision Name: Lot#:
EXPLANATION: D et`e 9 e( (h I k" f Cro ori-e CL 'In PA(Nro1
Signature: ` r l ��' Date: / U� / /7
Print Name: N/l 0 rt 1 (..1,1 .1 k p citS2 (AAA_
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 7/4, /2 By 0 Route to Records: Date 7 E, /7 B
Refund Processed: Date v/4 By #may Invoice Processed: Date By
Permit Canceled: Date 7/C.,//7 W Parcel Tag Added: Date By
i:\Building\Forms\RegPermitAction_092314'doc