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IRMA DELL
BUTTERFIELD
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
t 4 1 I 9 1 0
:Fri I. Request for Permit Action X_,
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 t7 City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
114 Mailing Address:
City/State/Zip:
Phone No.:
PL ASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
I
CANCEL/VOID PERMIT APPLICATION.
E 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#: ttOzoi'v- OOOO
Site Address or Parcel#: gpo S' LV14 a u.
Project Name:
Subdivision Name: JIrv041 Jk 4 Pcr-k Lot #:
EXPLANATION: 010 i I q-+ 3 0 og LAI Grit , c e.rrfir ` 2OIt ,3I (:d ly t)—
_. . P 'kd i4 .D V LI 1.. -0,-- rte.
Signature: LICDate: --i Z-1 q
Print Name: tL,ti u-d L 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
Route to Sys Admin: Date _ By Route to Records: Date .3 2tic t B '
Refund Processed: Date it/th By "f_ Invoice Processed: Date By
Permit Canceled: Date `;/ f c? )/ Parcel Tag Added: Date By
I:\Building\Forms\RegPcrmitAction_120518.doc