Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT v J '
Request for Permit Action // 4At`
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: ❑ Owner ❑ Applicant ❑ Contractor Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zi••
Phone •.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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#: /12577,40/r--
Site Address or Parcel#: j5Z255 ,s-z J //y2- 64.
Project Name: 1 p •iL v-c Cy- S e Vr rietf- t.,,�
Subdivision Name: Lot#:
EXPLANATION: , Gck "'✓,frG44-11 i,-//ee /r
!./7- J vcf�i� 06,4;70/t3"--(x)f -7 y.
Signature: Date: 677//
Print Name: Jr-A/1/47,4e"/ —
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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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
Route to Sys Admin: Date (� 7 ` . By 5', Route to Records: Date /j -- By 1`,y,'
w --R fuud,Processed: Date 7 /_ By . %7 Invoice Processed: Date / By
Permit Canceled: Date 4 q/j,e, By " Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_09 31 .doc