MLP2018-00003 VOIDED
MLP2O18 - 00003
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City of Tigard • COMMUNITY DEVELOPMENT T DEPARTMENT
.
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 (l Contractor City Staff
Check(V)one
VA" t i3 EFUND OR Name:
J � iE INVOICE TO: (Business or Individual)
GfraS
`K Mailing Address:
v} City/State/Zip:
j Phone No.:
PL ASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
La Colic 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#: 11 LP Lo ig` 00003
Site Address or Parcel #: 11759 SW cutalit J .
Project Name: FS ?1ruir L41I 1Prt,4
pe
Subdivision Name: idA" Lot#:
EXPLANATION: I Cr tjtj A,‘ Ft\ error~ ' 1 JONI T (AIL
411 CAA-P-
P I(O®3o, f(E Carr�fy (Jury) hi 4 }� P,�C?.-G4)-0603a. r4:04)
Signature: Ctftei Date: 3-11-1?
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Print Name: gamut( e'e th
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ./ .i- /A" By y,
Refund Processed: Date NM- By Invoice Processed: Date By
Permit Canceled: Date rf-ZJjr By,,( — Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_0 231/4.doc