Permit Support Document (14) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEN
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TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-o .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 iN City Staff
Check(1)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):
gCANCEL/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#: z/4,57-1 /5' d /
Site Address or Parcel#: ` 2I 6, 7 s„0
Project Name: SSL"✓'
Subdivision Name: Lot#: --
EXPLANATION: eee 57�cSY t•d' Sk G✓!•�//74,,e- it/es G
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Signature: /G�/� Date: ?Xl/tel
Print Name: Tu l7 it
lie uT"nd o cy
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 USE ONLY
Route to Sys Admin: Date "7 / l9 By i4 Route to Records: Date f=-/ /9 : �jt
Refund Processed: Date i �� :., ,1
Invoice Processed: Date By
Permit Canceled: Date 4Prh f B Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1 0 8.doc