Inspections City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT \ 1
1111 11 r
Request for Permit Action 7/3/// f
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 p Applicant ❑ Contractor ❑ 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):
0-''SCA CEL/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#: 6vr/q,;Zt)1/-ov/,3
Site Address or Parcel#: /)-3> ji:.✓ 4 I/S T ,Q
Project Name: /3')6._4,/7e. lam-/' J
Subdivision Name: Lot#: P----
EXPLANATION:
—EXPLANATION: ,6ti/°,7r)//-O0/go /_A.) :( S 1 �7 c:7'r--
, 2/?-CZ /,3I L,/Z4 r c :74_c../ <Arta ,-fes 'IV 7
ISL4pal i i tat.) i;S c,,,,,-.0- C r',-.r4, .l, SG G-' -,r1 4 OL)/C1 !J=:Lji Gly.-f Xctt ,. j 1) ,-.. /,
signature: 4 �_ Date: 7/Vi 9 1W13 3Aor of
y.
Print Name: .,t, , i -, --
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 7/3j t7 By .' Route to Records: Date 7%3, / By
Refund Processed: Date 41 4 By Invoice Processed: Date / By
Permit Canceled: Date 7/3///5 By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_ 0518.doc