Permit Support Document (16) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT' ' i
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lig it Request for Permit Action JUL €8 2019
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TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tiga pr gp; , _;',1
TO: CITY OF TIGARD V 0 Lp
Building Division eiy/A f
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPertnits@tigard-or.gov
FROM: p 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#: gu, zO( ` 60l(oO
Site Address or Parcel#: 10,),C,/`((. Sti.j /Co
Project Name: /t)Z l(l)or> // c l'
Subdivision Name: Lot#:
EXPLANATION: ,Z. s 11,,(� ,,c-' G!' a-7�Z� Gj
Signature: ft`OW ' P ate: 7(P//
Print Name: 7„4 if ✓Jhih l- �7 --
Refund Policy
't.-''rhe ci y'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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 LSE ONLY
Route to Sys Admin: Date 7 / l( By ,C$11111 Route to Records: Date �/, /7 :, '
Refund Processed: Date 4.1/4. B -�) ° Invoice Processed: Date // By
Permit Canceled: Date f/,// . By c : arcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_12 doc