Permit Support Document (38) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 1 0
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, . Request for Permit Action !2/z?/1? `—
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: p Owner ❑ Applicant ❑ Contractor ig City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) iOcnfrii Sr / wd-/So ki
Mailing Address: LQ S S- Lc' 2/ 5r C,.,
City/State/Zip: 7-4._,/G( OjQ 7 2,0,3
Phone No.: S/) 3 - Y 6 L/- al,/
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
Ei 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#: G.-/4.1 -/7. DO) R.
Site Address or Parcel#: `(75 S 5 5 Co �/ S T e.
Project Name: / Ie-4`d tag ,22.23
Subdivision Name: Lot#:
EXPLANATION: C V`Cafrd 1/17 -t/7'" / !i. C//c Shot la, Gravc
adwe,-.:( 7Lo tilsT 14col i7` A4 s7'-a017 -oopA 4—
AL..fiSignature: Date: /,z /,Z(p(0
Print Name: ul!; I61y lZ4e14. y.
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 C z/).,& By Route to Records: Date/V28' /7
Refund Processed: Date /l/ By Invoice Processed: Date By
Permit Canceled: Date /t/2,f/j1 By -Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_092314.doc