Permit Support Document (38) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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 TigardBuildingPermit • tigard-or.gov
FROM: ❑ Owner ❑ Applicant Contractor f I City Staff
Check(✓)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):
CANCE OID PERMIT APPLICATION.
- ND 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� J� /7-6b3(J"l.
Site Address or Parcel#: /605.1 S 1 t� 5 P�
Project Name: Li tle. ,114z
Subdivision Name: Lot#:
EXPLANATION: it ,A,✓V +.+�: . , , AA) 49 . F
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Signature: - Date: ////tik7
Print Name: � .,y �, ,tet
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 I E.(Q /7 By d .."7. Route to Records: Date 72- 2f
Refund Processed: Date Pt. By / Invoice Processed: Date By
Permit Canceled: Date /421-A7 By reel Tag Added: Date By
I:\Building\Forms\RegPennitAction_0 314.doc