Permit Support Document (5) VOID
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
III �iefl9
= Request for Permit Action
T I(; 1 R n 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 TigardBuilclingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ❑ 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):
zCANCEL/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#: U d,•0/ -- 610//10 _—
Site Address or Parcel#: /0 A U c S i ilii�.r re,(�/ _ l<
Project Name: to /I'm
Subdivision Name: Lot#:
EXPLANATION: 5 h,ice l .( Aa v- , ✓tu i4-� GLIA
At s-t. tate 5r. Sr . t r c 7-a.&/q- op/s'7.
Signature: #4/ / — Date: z-Zk.,
Print Name: Aid,.r On Ly u "--
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 LSE ONLY
Route to Sys Admin: Date z-/ /s By , 1 Route to Records: Date (,77/r 1 f? B:�`(4=,
Refund Processed: Date Af e9- B ,' Invoice Processed: Date / By
Permit Canceled: Date („fie,`,9 By — Parcel Tag Added: Date By
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