Permit Support Document (26) City of Tigard • COMMUNITY DEVELOP 1QT 'E T EHU:Pk/P
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41
Request for Permit Action NOV2 2017
T t G A lz D 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 •www.
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax>iO3-598-1960 TigardBuildingPertnits@tigard-or.gov
FROM: ❑ Owner ❑''Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 2 ru, pal �I L'0'15
5 i�
Mailing Address: e O t 'R Z ' 8
City/State/Zip: of q(42( 7 c't - 39 rg
Phone No.: 5-03-- 6z-Y - 4/kr?)
PLEA TAKE ACTION FOR THE ITEM(S) CHECKED (1):
El CANCEL/VOID PERMIT APPLICATION.
D REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
0 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: Sl"-)4 2_0( - 00 3cfe
Site Address or Parcel#: I 5 (Z�b o�Q 3 C
Project Name: eC6,Y L( Ve ��-.
Subdivision Name: (Nr,11=3"1-‘ Lot#: AO 3
EXPLANATION: i I C7 L�:441.0 � ,�i 11C'�
LA -LL 6.4- a. ' s 74DCl�t of Zts--
Signature: Date: Y/.7
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Print Name: �� y- K���,�.� /
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 71/7 By " ��eRoute to Records: Date / /7 By f
Refund Processed: Date By I �� nvoice Processed: Date By
Permit Canceled: Date // ‘,//7 By ;fair a, •.real—Tag Added: Date By
I:\Building\Forms\RegPennitAction_0 314 oc