MMD2018-00053 VOIDED
MMD2O18 - 00053
OUR REDEEMER
LUTHERAN
CHURCH
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTIIIV (i) 1 ,
IIII
= Request for Permit Action //i// ,1.--- '
1-1(.-JA It D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or. ov
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 ® City Staff
Check(✓)one
REFUND OR Name:
INVOICE T O: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCE~L OID PERMIT APPLICATION.
C 1.. D PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
n REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: MMD2018-00053
Site Address or Parcel #: 13401 SW Benish Street
Project Name: Our Redeemer Lutheran Church
Subdivision Name: N/A Lot #: N/A
EXPLANATION: Application created in error. Should be a CUP case not a MMD case. Please
void. Thank you. (c_Cr� (`u/ ,2 1/e-®Q fJ e' )
12/4/2018
Date:
Signature: Ilialb. -..2._
Print Name: Lina Smith
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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/ /f /9 By j
Refund Processed: Date/V/4- By,/97/ Invoice Processed: Date By
Permit Canceled: Date /ht./9 By„ --Parcel Tag Added: Date By
1:\Building\Forms\RegPernmitAction_A9231 .doc