Permit Support Document (36) 0 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT \/ 1
1114 Request for Permit
q Action
T I , R I) 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 ❑ Contractor ❑ City Staff
Check(v')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 #: — L
Site Address or Parcel #: ([3 11 Q 5z J /t eft st
Project Name: 44 C. /rod
Subdivision Name: Lot#:
EXPLANATION: e r ` /
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Signature: t Date: 7%12/
Print Name:
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 7 ByRoute to Records: Date ///L /� B sT--
Refund Processed: Date /i f- B ,�'�/#4, Invoice Processed: Date By
Permit Canceled: Date , ,/ f- B,-.k4 Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_09_314. oc