Permit Support Document (19) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT J-i ' 9 L, i 4
N = Request for Permit Action
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TIGARD 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •w\vtiv.t1gartl ur.gtn
TO: CITY OF TIGARD V 0 1 0
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 /3 /
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuiidingPermits@tigard-or.gov
FROM: ❑ Owner Applicant / ,Contractor ❑ City Staff
Check(✓)one - 1
REFUND OR Name: f[ \\
INVOICE TO: (Ausiness or Individual)
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Mailing Address: ('q q 7 E. 3.4 eri$ dQ s,-
City/State/Zip: 7k.- '(cc* /OK_747 7233
Phone No.: ,5-6c3 (4*-7- E`i?-C3
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
a CANCEL/VOID PERMIT APPLICATION.
fia REFUND PERMIT FFFS (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
0 REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit).
Permit#: ?LW( 4 Q ( V-- 000 3t-f
Site Address or Parcel#: J 6-15 o 55 3 , Su tnrneY'.(Zc,id. , rl-
Project Name: Y-r-6t_ I
Subdivision Name: S LI.Mt in e r- i ('l,0.1 Lot#: 3---- --3
EXPLANATION: e e,Ae44. `1-7) A Ad C-e_ ry.tA te &-- -ovv c-i.- 4
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Signature: �,f t__9 iilk. Date: 92,//
Print Name: k Son"i-On
Refund Policy
l. 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ur 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 postai service.
3. Please allow 3-4 weeks for processing refund requests.
Route to Sys Admin: Date By Route to Records: Date c.:/,.,7.2 /9 B
Refund Processed: Date//02.3//I By / Invoice Processed: _Date By
Permit Canceled: Date /�.s//,Y B Parcel Tag Added: Date _ By
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TIGARD
City of Tigard
March 1, 2018
Jay Jay's Plumbing
Attn: Ken Smith
19947 E Burnside St.
Portland, OR 97233
Re: Permit No. PLM2018-00034
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 15505 SW Summerfield Ln.
Project Name: Rytel
Job No.: N/A
Refund Method: ® Check#227712 in the amount of$81.20.
❑ Credit card"return" receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account"deposit"receipt in the amount of$
Comment(s): Per applicant's request as this was a duplicate permit taken out in error
(see PLM2018-00023). Refund 100% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov