Permit Support Document (3) I 11
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTV
II
,',01 : Re quest for Permit Action �`° ` 9 .61'1V
TIGARD 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 ❑ ContractorEl ity 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#: 5-64)/Q, -)/1 - CCY c
Site Address or Parcel#: 6 15 3 5i,) t.� ',0(.4.T
c'/
Project Name: kjlz'_ ,4,
Subdivision Name: _ Lot#: - '—
EXPLANATION: .�,• %i `" t1;� SZ < :tj:-,S---- i';':/C.,'
"7`z,
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,AL3-7 _,--.4/`�- of -{r_eJ & +137 -,,1'j. gc-.-d'--f .m,t G;.,4,, ,&.i b-e. Li) .e
Signature: Date: i/73,/I
Print Name: 467.-4/V-.06..., �7
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 !y //'j By ./ . Route to Records: Date By
Refund Processed: Date 4 By Invoice Processed: Date By
Permit Canceled: Date (o 6I/9 By 7-Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1 0518.doc