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Permit Support Document
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 w ■111 Request for Permit Action . T I(_,A R r7 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 •;ww w .tigard-or.gov TO: CITY OF TIGARD S - Building Division - u u 13 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-,©r.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor -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#: ,//,‘57?,0/0 - 0002 L14-- Site Address or Parcel#: 1/ 77 '1 St} 5iA,r r "-? Project Name: fel.G.CS .7--- Subdivision Name: Lot#: /`7�C,9 �l/i i t_- EXPLANATION: 2 piz��7 7 ( / , _�evI-4if7& k it-f---Ct,l�` �7�'� rt AL1 r�s, -/' �i i `• ---A , ( //ccs , / (c /4,.. 6,-/- i s . /7ETG ///t' ,_c9O , /3 , Ifi., _. Signature: ,0/1 --4 Date: ?�/Ad., Print Name: ru(f1 r-* i4y`n -,' 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 c ,0 j /I By I Route to Records: Date 7/ /L /j--- By -• ' Refund Processed: Dau /A.1-S B __I/j_ Invoice Processed: Date By Permit Canceled: Date j�// //f i By ' , Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_0 _314. oc