SDR2015-00003 r:1 1
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT /1/4//.7
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Request for Permit Action
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 61 City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) / 4.
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#: /71)/ 10.57-00007 10.57'-00007 W2C/c
Site Address or Parcel #: g l b 75-0 $f Q rr c 6 V s
Project Name: /?+C A-Prs
Subdivision Name: its 4-- Lot#:
trEXPLANATION: N`ei n7 (iCWrtDes Foil_ kC Sr itpv 2D1(D-600J' -
'✓o i D S ?nt Zig A pfr rov►4-L _ ,7.f s Ata c woxlg rid.ate! e 16
2 0(7-i.Proo0 t/5 2o/ -by ' i /VGA A/E711 V1 r2—J A:74 6-1/2->i .
Signature: t2 Date: /1^
Print Name: ,
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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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date By Route to Records: Date /j b /J B
Refund Processed: Date NM' 8Z) Invoice Processed: Date By
Permit Canceled: Date j//i Jj7 134Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_A231/4.doc