Permit Support Document (19) }
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT114
a Request for Permit Action NOV rzk 2018
TI6AR I) 13125 SW Hall Blvd. • Tigard,Oregon 97223 • 503-718-2439 •www.tiga r TIGARD
i'11P N.
TO: CITY OF TIGARD j
Building Division V ' I
II
13125 SW Hall Blvd.,Tigard, OR 97223 f. ./,/ e f . i
44
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@riga d-o .gov Y/
FROM: ❑ Owner Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) i !) t`, vl �j U�L U
Mailing Address: 0 3 VOO I wo
City/State/Zip: V(/1 V L o(A v e v G( )LQ U90
PhoneNo.: 31LQD 043-1-1()C)
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
®. CANCET/VOID PERMIT APPLICATION.
III REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
1.1 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: 1`7S i�/ �C��%3 ._�GcJ cC!/� -QLD J?
Site Address or Parcel #: t V)CN C2\A, f y 1eWk1; 1 rA 111J
Project Name: V Y , C&(j CA KCA J
Subdivision Name: [ ' JJC (� Lot#: ' l 0
EXPLANATION: --�"
t/2-V ici ..a cr s7 _ ac Lie er-ew 7720-r r:lee
Signature: �- Date: t I wI
Print Name: V / c V A c, t'i v rv\
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 Route to Records: Date /02.3 /1 By l
Refund Processed: Date A/70 By Invoice Processed: Date //,,f)/9 By`;i
Permit Canceled: Date /Z // / ' B /o Parcel Tag Added: Date / By
I:\Building\Forms\RegPermitAction_0 _31'.doc