Permit Support Document (15) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTV 0 1 0
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Request for Permit Action 77 7/4— 444—
TIGARD
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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: ❑ Ownerpplicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name: h `-
INVOICE TO: (Business or Individual) C', a `e f
Mailing Sw
ailing Address: j 1 Z OA)
City/State/Zip: r\ � '4 ! a (( -%
Phone No.: q'-1 C a -4 0- 3
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
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#:
Site Address or Parcel#: //6 .�.A f /f$' vr.
Project Name: (DG/(p L4
Subdivision Name: Lot#: --
EXPLANATION: C '�'� :s - 7 d' cv✓ e- t 4�.f
e.,- /:;:e_<-,e-1-6.1/ Aeivr._ 1.t." ect...7)-1 '7elf\ta"1 r<ei I
Signature: Date: ` -`ji- "
Print Name: `'
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 g" rg" By Route to Records: Date fv 2-3- ,f- By
Refund Processed: Date By f Invoice Processed: Date By
Permit Canceled: Date �� y !e- By t '41. Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_012314.doc