UFR2018-00005 City g of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ,.
= for Permit Action 7/0"
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: El Owner ❑ Applicant El Contractor Ig City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
116 c(6 Mailing Address:
rte. \Ater\ 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).
El REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: UFRLO1-O00os
Site Address or Parcel #: Z S I i2--C 8 l270O
Project Name: COP.bi 1 Cu 6o.i4(?)/) 'UrLA Fins i-r7 I� h4 i Cit f i M
Subdivision Name: Car 6k cog i viM0' Lot #:
EXPLANATION: 1 cre rtJ UF . use t r d Hvd- Ig.S Z0.ate. g pr .
+KC stl iS. wcui ut c Ce 11 e,14.
Signature: Date: Ss 14-'0
Print Name: S4 ANA, � c(u„
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 .5 /f' - B ��:%�_
Refund Processed: Date ,4- By AOW Invoice Processed: Date By
Permit Canceled: Dated/��/I B 4 '' Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_ 92314.doc