Permit Support Document (62) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTV 0 1 0
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Request for Permit3/200 9 a---
q Action
TI G A R D 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 ❑ Contractor g.£ Saff
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):
CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
D INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: - i/ - Oa)12
Site Address or Parcel#: (5ZG)5 j ^]
Project Name: 671-1 St/file—re- ( /'t (e-
Subdivision Name: Lot#: —
EXPLANATION: • —)C U 1 19,oi,
fl /' ii- ;) / -1 - 5' ski /S"i I, r c,..c r rer•''t A e- S 7Z �.
Signature: ---------mate: 02/01-7/1c
Print Name: a-7.p✓a 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date 02 /9 By Route to Records: Date.3 Zp /yRefund Processed: Date ,d' BOW..., Invoice Processed: Date By
Permit Canceled: Date � �F )? Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction 120518.doc