Permit Support Document (60) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
2 Request for Permit Action
TIGARD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARDVI0 .
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 2ity 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):
CE7 CANCEL/ ID PERMIT APPLICATION.
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 PERMIIIT (do not cancel permit).
Permit#: ,SCJ I AC f p -000%o?
Site Address or Parcel#: /6 '--4 i"/ s(n/ th, G Gj l /r
Project Name:
Subdivision Name: Pe VZ',' ga. Sr- Lot#: /6.0
EXPLANATION: C YCa fr„, cr ceec,,ar
vt r/(O1. .S' -; iGl/L- Ofd'--f,ee7,'/)
Signature: /91e% -41Ler Date: //e//F
Print Name: !dcor/C G
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: Date 6`�. Y / " By
Refund Processed: Date "(1.71--- B B Invoice Processed: Date By
Permit Canceled: Date ,A1,23, / By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_092314. oc