Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
» Request for Permit Action
Rou 2018
T R ii A R n 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 •www.tigard-or.gb\'
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 IS..City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE T'AtI :ETION FOR THE ITEM(S) CHECKED (1):
CANCELJVOID PERMIT APPLICATION.
REFOND 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#: 2Lr'AO( Ts- onc—,ReY
Site Address or Parcel#: 1�� S S LJ /.z fy. L i •
Project Name: /u i!y t/ S
Subdivision Name: _ / Lot#: --
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Signature:
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Print Name: S r Is'c �fihiebt- */
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date ,F /t- By Route to Records: Date /c+ / By
Refund Processed: DateJ/'� B Invoice Processed: Date By
Permit Canceled: Date The/d'' By 'Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_ 231 .doc