HOP2018-00041 VOIDED
H0P2018 - 00041
AB CRISMAN
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Cit1,1y of Tigard •• COMMUNITY DEVELOPMENT DEPARTMENT Vi 0 ! D
Request for Permit Action 4//f /1 ory----
T!GA R F3 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 ,City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) One
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
ANCEL/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).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: -1-/0 Pao/g_ 000"f 1
Site Address or Parcel #: /ii( j SW O'/ �fr S 7&'
Project Name: i S�Q,�, 1
oxt (r, u,
Subdivision Name: / Lot #:
EXP • ATI ON: r• /4 i A . d... ,‘C a T/
M f4 a . / Ir 44 • C)C-4-- 'gar C 7- - 'e/✓ T -4,4_.
Signature: Date: /0/40 I
Print Name: .-____:15 c `"Y er— wa./.ppv-,
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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/7 /9 /1--- By.der-r—'"
Refund Processed: Date i1/4By, Invoice Processed: Date By
Permit Canceled: Date 4`.?/// By arcel Tag Added: Date By
I:\Building\Forms\RecPermitAction_09'_..314. oc