Permit Support Document (34) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action v 0 1
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov 4r/25h
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 X City Staff
Check(V)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
�C 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#: 44 STA f OO/vr
Site Address or Parcel#: 13 03 5— S4) j'/ S
Project Name: t G r —S7e-1^
Subdivision Name: "' Lot#: '—
EXPLANATION: 6- c.c."( -(j'd 43
YreA7-( ( h cr 1411 ----&Kr-• zepj
Signature: *e /4 • ' - Date: �j„Z//1-
Print Name: ,r l
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 rt /f By % Route to Records: Date ' 2-S By'''
Refund Processed: Date Ai 4- B Invoice Processed: Date By
Permit Canceled: Date / Z6//4P' By i� Parcel Tag Added: Date By
I:\Building\Forms\RegPemutAction_09 314. oc