HomeMy WebLinkAboutPermit Support Document (61) 1
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Cit ofand • COMMUNITY DEVELOPMENT DEPARTMENT 2 ,
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_ Request for Permit Action
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T f C;A R n 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
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TO: CITY OF TIGARD
Building Division 2019
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuilditxgi'ermttsti ,xd7pxtgov
FROM: ❑ Owner ❑ Applicant ❑ Contractor gity 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 (✓):
ffCANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule andmeprovide explanation below).
Permit#: l U �Q�(2L -•G'VD2-2
Site Address or Parcel#: /3,3 3 7V S&) Ti"cdryyta t7
Project Name: eOf'a
Subdivision Name: Lot#:
EXPLANATION:� (° ��cz�(-GC Gr &tP cal r� S�?%rtit-Grp G�GGG�
L° ►2'-gutltS7'' m ST)- / 9 -0(5Old
Signature: 7J/
i Date:
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ONLV'
Route to Sys Admin: Date J1 By Anil Route to Records: Date 3 /9 :J
Refund Processed: Date A,1 By Invoice Processed: Date By
Permit Canceled: Date 9 By4W Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_2051 .doc