Permit Support Document (16) City of Tigard COMMUNITY DEVELOPMENT DEPARTMENT'IN . ';
Request for Permit Action Yov�7 4
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon gon 97223 • 503-718-2439 • waw.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPertnits@tigard-or.gov
FROM: 0 Owner 0 Applicant ❑ Contractor Vf City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
P. - 11o..
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
0 CANCEL/VOID PERMIT APPLICATION.
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#: 5 10 1/2,Ao(7 — C30,30.7
Site Address or Parcel#: r/ C/ 71 64) ����d /tom
Subdivision Name: Lot#:
EXPLANATION: !fir or i ' CV za'75- cy,lat.
Signature: Date: lU h�l7
Print Name: larcit
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ,, , /7 By
Refund Processed: Date AI By 1177 Invoice Processed: Date B
Permit Canceled: Date y
�r�� �� Bye �=. Parcel Tag Added: Date By
\Building\Forms\RegPermitAction_6923 4.doc