Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT / 0 1 0
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Re quest for Permit Action /AO q "
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T 1(_,A R CI 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-24 • " vw -or.gov
TO: CITY OF TIGARD NOV 2 0 2018
Building Division
13125 SW Hall Blvd. Tigard,OR 9722ix
3�_�¢
Phone: 503-718-2439 Fax: 503-598-1960 Tiga`rdBuild ingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ❑ City Staff
Check(i)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):
CI..._...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 CON TRACTOR ON PERMIT (do not cancel permit).
Permit#: /v(r i o -,U l F-- D CJ c?d s--
Site Address or Parcel #: `(-'(f ?3 5 I C S
Project Name: Kc C
Subdivision Name: Lot#:
EXPLANATION: 5hUe,e,(� li!_c�*/- c2 C'zap �E G
116414 Gi< /t l!( 4 pg S7` p-/- c -
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Signature: t I //Date: hr
Print Name: j ft r 1,0/1%n k1.t /7'i
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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/f z ti By I7 Route to Records: Date //r/y B 44.---
Refund
G.— -Refund Processed: Date N//P B 4,./!_ Invoice Processed: Date By
Permit Canceled: Date //lc/y By,6096/---- Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_ 923 4.doc