Permit Support Document (13) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request JUL2 9 20,0
q est for Permit Action
IG A R[) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.ti ardib off' ,,
TO: CITY OF TIGARD r
Building Division 1 ;
13125 SW Hall Blvd.,Tigard, OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor / City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) kAN-7-t k,01
Mailing Address: w�
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#:
Site Address or Parcel#: C.&\ %("Nic ('' , ( TO)
Project Name: � Z��'�j, S l 1 ...
Subdivision Name: Lot#:
EXPLANATION: \ CCtit cc E ,(L ` , C, 'c ,A
Signature: --`- Date: y<
Print Name:
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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`-- )ret r,C1 By S'+;' Route to Records: Date 47/ / q By
Refund Processed: Date AiiB Invoice Processed: Date By
Permit Canceled: Date 609//1/9 By,4 -- Parcel Tag Added: Date _ By
I:\Building\Forms\RegPermitAction_12651 .doc