Permit Support Document (11) „i,7-2 te-- ,ei6(--- „., . ., , .
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ..1!.:;,i 2 1 L sf3
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{= ' Request for Permit Action .
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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: ❑ Owner ❑ Applicant ❑ Contractor pit 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 (1):
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#: u .,?(/J F” Da W,,,
Site Address or Parcel#: /6,0 F,4 ,S'4, t( / 4 JT/-7c,.c Fr/? /‘,/' ISO
Project Name: t9'4r'•part- Cf -l/�/ v/r�c j is
Subdivision Name: .-----'- Lot#: --
EXPLANATION: C%✓ .•G6'7z'� ,r rive-,// '1--- )1.1 Gt,7o vt_z s Lr />1-c...4 144 kr 54vvr(�1 %cet,'- //JCrG/ $/-r/7"r- .?gyp.
Sr.c i4-ikr-c I Atez4i ,rr 44, Wil, I1 '1 )15, • /
Signature: ��/ Date: C� / 4/-
Print Name: Tu( . ,t "t)4&i,1/!-ry�,_7-
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 t SE ONLY
Route to Sys Admin: Date (p!, By ii, Route to Records: Date ' 2- //-- B !.b,:''
Refund Processed: Date A/ By 11'' Invoice Processed: Date By
Permit Canceled: Date f'Z 4.- Bye tip Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_092 14.doc