Permit Support Document (59) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
III I •
Request for Permit Action
TIGARD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division13125 SW SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLSE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
nCANCEL/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#: /J/ic"C®Z Of T'Cag
Site Address or Parcel#: `cc'g S-- 6 4) /Y1y07/z'1-vU,,,-
Project Name: / /
Subdivision Name: ths.rt7 o (%'Ss 'Ares Lot#: 117
rr'OlEXPLANATION: _,j hcvu ��� Li..,,„-
Olt/e
t/Cavi Cy'asAKS_ G Ojer-itase c Cud ries “7--aAce ✓ever/411_,
/1' 12, ,46r.
Signature: Date: l/!C/7
Print Name: ;j//i j4/'oM frj 1r/
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 / `4 (- By Route to Records: Date p / By
Refund Processed: Date 4,///9- By - Invoice Processed: Date By
Permit Canceled: Date 0%23//J- B Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_092314. oc