Permit Support Document (14) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT/ l
NI Request for Permit Action 570,44V-
TIGARD
,TIGARn 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: El Owner ❑ Applicant ❑ Contractor ity 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):
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#: f ,.- Je"
Site Address or Parcel#: C/C)k) S tc INCIZIA) t,
Project Name:
Subdivision Name: Lot#:
EXPLANATION: 6-r t Merv, i , T L.( ys ) 9(
e AI az-(c_ f .-, .; iV 1 fin.s7/ i( jt K--COC 71
Signature: : Date: j//l Ji
Print Name: / ,j` (1941t-
�"
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By /5 Route to Records: Date /e- /f B
Refund Processed: Date ,tl///9" By 14414
Invoice Processed: Date By
Permit Canceled: Date S/4 /, By -,-_i Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_69231 .doc