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Permit Support Document (62) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTV 0 1 0 `� _ 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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