Permit Support Document (14) VOID
City of Tigard ® COMMUNITY DEVELOPMENT DEPARTMENT 0./2//04-- ~'
III at
Request for Permit Action
TI G A li D 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 •www.tigard-or.gov
TO: CITY OF TIGARD JUL 2, '1,013
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigaixi=or.gov -
FROM: ❑ Owner ❑ Applicant ❑ Contractor kt 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):
Et 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#: EL_fec),/� �D/DlJ
Site Address or Parcel #: Hy.? 2 5�
Project Name: 16l/j4/h yrs 7?1(d
Subdivision Name: Lot#:
EXPLANATION: a ` _1
Signature: i �� Date: 7"/r
Print Name: u 4.7- Ori
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 I_'SE ONLY
Route to Sys Admin: Date 7 3 l, By Route to Records: Date B 47
Refund Processed: Date A/ I By Invoice Processed: Date By
Permit Canceled: Date I/0,k"' By , r Parcel Tag Added: Date By
I:\Building\Forms\RegPemutAction_0923 T4.doc