Permit Support Document (29) 0 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT v 1
III a Request for Permit Action
T I G A R n 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
3[r 1 ? f.010
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 '4 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.
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#: AW /7' 0105a 5'3
Site Address or Parcel #: // ( t
Project Name: Di S e c€,7--- 747Yr
Subdivision Name: Lot#:
EXPLANATION: nt— !/4 Z'Gt Gr 7- --7,z7 c !r c‘,;(-1- Cc Gj -Pfs /4-c/4/1Y--
10k74-
Cccnid--
/o'74- e' ttr A 614 t%f2n -i /• Av- Cit,i/
C'✓ -e r ( ! Fps /4-Y/44 AZ)
Signature: ) , Date: 7%L//7
Print Name: Yu Ic bri kr
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 Pr Route to Records: Date j/ `�, 4.p By
Refund Processed: Date A/ Z/f- B ,,ii Invoice Processed: Date By
Permit Canceled: Date ,hi-- By ; Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_O�-314.tioc