Permit Support Document (7) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEN
Request for Permit Action G f f
TI G A R[) 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 1ty 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):
▪ 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#: /1'1712'
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Site Address or Parcel#: 15 ilit5A, ✓ �
Project Name: d=L i1
Subdivision Name: ' ✓ J Lot#:
EXPLANATION: n �z .7 ,h.0
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Signature: � Bade_..__ 5.--/Ay
Print Name:
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 6-7/kr By ; Route to Records: Date &(4 By
Refund Processed: Date ;./1By Invoice Processed: Date By
Permit Canceled: Date 4149/,q By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_126518.doc