Permit Support Document (19) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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II = Request for Permit Action /212‘n 2 44W-
TI i:,A R.1-) 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 ity Staff
Check(✓)one
REFUND OR Name:
INVOICE TO• (Business or Individual) r.�vc.t.Gty 1•4., gra�LGtie
Mailing Address: /0 7 7 0 5.A; (,J4 ik u T S7
City/State/Zip: 7--;�(,r vr� a,,e_ 7223
Phone No.: `I 7/ - S7)C., -- S-5-",.
PLEASE.,_TAKE ACTION FOR THE ITEM(S) CHECKED (1):
4_„2„.1e,
/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#: . ZiJ iiQ•ZU/7--00 32/
Site Address or Parcel#: f a 7?o S&' AlG A t 7 s
Project Name: (4 vt ret / 'cc(4'12 C c.-
Subdivision Name: Lot#:
EXPLANATION: 5 rct7-r prem..,,./--- SW(2,, o1,c - coo 7 0
41 i/ ra d6 r_yI's it.'
Signature: Date: a(,z. if?
Print Name: u fi G Oink/etc,*IV'
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 /,Z G f? By Route to Records: Date/2/2_g 0 By
Refund Processed: Date A/ �" By Invoice Processed: Date By
Permit Canceled: Date /2/?.i,//, By arcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_0 314.d c