Permit Support Document (23) V
0
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0 1
i . 4
'PI Request for Permit '(//o /,
q e nut Action
T I G ~,R[) 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 ❑ Contractority 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):
CANCFT /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#: Se.tij2L /rl " <, c.`
Site Address or Parcel#: .7 U SL-J /4+ii ,j>t ,' / ,,i,
Project Name: /Ae 1;61e'l .-- `t j i-V-�ttI
Subdivision Name: Lot#: --
EXPLANATION: 7i,-/ A t A-z-_-0, ext4 S%,-/- n-e ,,. ,--t' 14vj'z;c.I Z7,Y //d,
r,//f v-- 7'1) ,�14----v rr_,.i: 4... _ .% ‘_-_,,e-....1---,-( s v41rj/y—c-.v<. f i4-7%r-
/I 1„/ '-e a i'-r t _ _.7 E..,s r 1 ,S "llz.z.. we._F' .S -c.,..c.r i I- , //
Signature: y . 7z. c_ Date: IM7l f
Print Name: e,,-;74.4.--...-4-,,, �.
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 '"-r ,aS S B `'-', Route to Records: Date// /6; /".-- B •te"-,
Refund Processed: Date ff- By 41,;7'i Invoice Processed: Date By
Permit Canceled: Date /1 / /. Bye Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_0 2314.:oc