Permit Support Document (59) ,8 r dilr
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTM t"R 1 8 -,,,,c19
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Request for Permit Action ]
T I G n R I) 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: D Owner ❑ Applicant ❑ Contractor 151-City Staff
Check(V)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).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: 2 : Zc-) , OO/60-7
Site Address or Parcel#: 1L 6,S3 7 5/,,/ 5 ,c4 c�i� �,,,s7
Project Name: ✓gyp 41-0Y1 �� S/a L` / ,c-4
Subdivision Name: I ( (e it (-/ Lot#: /z16.
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Signature: Ae/4-. - Date: j -//
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date 3 i (e. By . Route to Records: Date 9 / /� By
Refund Processed: Date 7L/,r 9` By Invoice Processed: Date By
Permit Canceled: Date ` 5/8//9 B Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_120 7 doc