SGN2018-00040 IN City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT kfr el%
i 11 Request for Permit Action ,...„,
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T I i,A R[, 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 n Contractor Z City 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 (✓):
® 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 #: SGN2018-00040
Site Address or Parcel #: 13939 SW Pacific Highway
Project Name: Providence Express Care
Subdivision Name: N/A Lot#: N/A
EXPLANATION: Permit was created in error, and incorrect fee was invoiced. Please void the
the permit and the invoiced fee. Thank you.
Date: 6/21/2018
Signature: _ _ r—,— /
Print Name: Lina Smith
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 Route to Records: Date 45/2.2.- /41— By •
Refund Processed: Date rt1/4By X11. Invoice Processed: Date By
Permit Canceled: Date 6/2,7,14-- By 'arcel Tag Added: Date By
I:\Building\Forms\RegPlermitAction_ 2314. oc