SDR2019-00001 VOIDED
SDR2O19 - 00001
TIGARD SUITES
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City of Tigard • (.oNlNll1Nl l'l 1)l vl�:l.�)l>Nll:N'I DEP 1RTMENT� `" '
-3/2609
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-3/20j=. Request for Permit Action
TIGARD 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 ity Staff
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 (✓):
CANCEL/VOID PERMIT APPLICATION.
n REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: S D 90 lq-006 0
Site Address or Parcel#: 15‘)FO 56V
Project Name: ,ri 5,; "es 474/
Subdivision Name: Lot#:
EXPLANATION: 6'5 d/�'1�,� 74r-4;041 >1 c), 7`
5-(;) op/ic 0 he:, -71 71U.^ &)C./4, 71-11.4,7 War.", 5.6-4
Cpm 1 k�P , eve o t/ .
Signature: Date: ,. /,,W/9
/, `/5
Print Name: 5' t , 1,(,-- /1,4',,,re,�-� /
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 3 - /tel
Refund Processed: Date /✓/�9' By .4747 Invoice Processed: Date By
Permit Canceled: Date 3izf/'? By4 -. Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_ 205 doc