Permit Support Document (13) VOID
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
114 - Request for Permit Action
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: ❑ Owner ❑ Applicant ❑ Contractor 2 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.
t u REFUND PERMIT FEES (attach copy of original receipt and .rovide explanation below
p p )
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: f/-iea?,i)Ig -066 L�
Site Address or Parcel#: A11, /it ► / /6'0
Project Name: gowr fr�`' aif,/gs.$ /Ord('e4i-re
Subdivision Name: Lot#:
EXPLANATION: C, yea `t � Gt GC /4:Z_A. /vit!7L kci
S4o1a(c -7kf-t
C.Ci/Kt i f z-714-= (T , .erL-kr 15- SGC.d • /. F-moo,-/
Signature: Date: 7 ,>
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 7 �/ (i By Pirml Route to Records: Date , /��— B
Refund Processed: Date A//,/ B 4,-* Invoice Processed: Date By
Permit Canceled: Date ��/,4- By ♦ y arcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_0 2314.doc