Permit Support Document 1
VOID
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTUPI
c
Request for Permit Action _y2,/,-//
q
eiv
TI ;ARD 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 IS ity Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE AKE ACTION FOR THE ITEM(S) CHECKED (✓):
S 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#: /1—C.66 j"-`''
Site Address or Parcel#: ---741/446 -- k \ttyC\, S 1 WQ
Project Name: /l/dile —
Subdivision Name: �— Lot#:
EXPLANATION: -.1 ,7` ut5 G lleS. ,•v j „i„,,, "j- „,„:7-
ez l V� ✓yve 01' �-// -i>`' T y 7`ju ? t/er r->7e,ec-c.
a=t />'s ri="4e-e- i cit^7h 75,,Lucf 77Lz Lk I Vte u> y- .c ��_,X ---ff.. . 7L7L47^i
i //i': '.eed 51.... x- wz l4�Cs�' ?)1`I—csu�) ?L 7t,
gnature: � � . e i Date: If,-
Print Name: � .2 �„-." / ,
/5` t
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 r '"/I By -" -7` —� Route to Records: Date ;27f /9 By
Refund Processed: Date A/ ,4- By •i'- Invoice Processed: Date By
Permit Canceled: Date3 1-l' B ' Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1205 8.doc