Permit Support Document VOID
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT b/p° lq IN
= r Request for Permit Action
E T }
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard °i` L.:,1
MAY 23 2019
TO: CITY OF TIGARD C
Building Division
LU) .,) i
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor .,e'City 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 (1):
R. CANCEL/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).
Permit#: EL-e°eZol ,+ 0C)31--/r
Site Address or Parcel#: t 3 773 6"it.) '071'
Project Name: 4 ri4 L1G/<'14
Subdivision Name: / Lot#:
EXPLANATION: ,S U!G c �rd# /7 C K cc s- r�
C(r e- -ecc/ ./vii t Lt,t1 re( S/�c.0 rte/ cc o r
t el c tce or/ at frtel--- C1 , 57—1,z-/ ft- C,I4 cr).6I c —Cr)///)•
Signature: S
I i7 / Date: 57: ��
Print Name: Vub', 4}q -& -j
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date et.$ /7 By Route to Records: Dat ` ro tc.
Refund Processed: Date jJ)y By Invoice Processed: Date By
Permit Canceled: Date 61/40/i 9 By -Parcel Tag Added: Date By
T.\R.,;lA;rtg\Fnrme\Rr7Prrm;tArt;n,L1 51$Anr