Permit Support Document (15) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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Request for Permit Action
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T 1 G A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • w\vw. i and-or.•ov
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TO: CITY OF TIGARD JUL 9 2019
Building Division $ z
13125 SW Hall Blvd.,Tigard,OR 97223 t 3
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Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits a7tiga:rd-"or:godv"
FROM: ❑ Owner ❑ Applicant ❑ Contractor [City 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 (✓):
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#: , c7:01 / "aC ,c2
Site Address or Parcel#: l02 1 Z S/i S'ti(/!7/4
Project Name:
Subdivision Name: Lot#:
EXPLANATION: t,t/4 ' -e.y/E a rrS t/ 7 ke/
Pl r twc doa 7 y.
/44:00.;
Signature: -if
Date: 7/47/.7
Print Name: � O// -n
ReI'una-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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
Route to Sys Admin: Date 4 By '
Route to Records: Date �je
Refund Processed: Date 4'4 B.r 41 Invoice Processed: Date By
Permit Canceled: Date t7(//i By.4t Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_120518.doc