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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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Request for Permit 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 r4 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 (✓):
.a CANCEL/VOID PERMIT APPLICATION.
/ „.3..- PERMIT FEES (attach copy of original receipt and provide explanation below).
SIINVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
/ /' 11errnit#:
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Site Address or Parcel#:
Project Name: CcctCo
Subdivision Name: Lot#:
EXPLANATION: Cjin perry-1R pp,.. ,2f)P1 a vyt etreinSer
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Signature: ,r d ock l'” Date: 24 ii 13
Print Name: '.lei GS 1.--f ,a r
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ONLY
Route to Sys Admin: Date By Route to Records: Date y Y /p By,/Zie
VAN&ft-72---Ake f Ti Processed: Datey y/f B -4, Invoice Processed: Date By
Permit Canceled: , Date 3 esz 9 /9 Byes• arcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_Lug i u.aoc