Permit Support Document City of Tigard •' COMMUNITY DEVELOPMENT DEPARTMENT RECEIVED
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Request for Permit Action JUL 2 2019
TIGARDS 13125 SW Hall Blvd. • Tigard,Oregon 97223 • 503-718-2439 • w\vw.tigard-oklIy OF ! UAHD
3IJI DIPIC DIVISION
TO: CITY OF TIGARD
Building Division if I r
13125 SW Hall Blvd.,Tigard,OR 97223 4)'/i./r 49",
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: E Owner ❑ Applicant 'Contractor ❑ City Staff
Chcck(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) r _ v d t1 LCC - __ u. e, Me.kie.r.
Mailing Address: ,(j C 13 N -. -CIZe\ )eA l A u t 01
City/State/Zip: \ [umzs v ei i LuA g slI y5
Phone No.: (5 03) X'('-1 -i21-k
13
PLEASE TAKE ON FOR THE ITEM(S) CHECKED (✓):
CANCE - D PERMIT APPLICATION.
q��:� '. ; PERMIT FEES (attach copy of original receipt and provide explanation below).
rl ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit #: tV\1-C, ZO \9 - COL45(n
Site Address or Parcel#: . - ^`-- --5 t v. Vit" \\y'---\y ¶ v3 \F-3A\-\ e. .
Project Name: —i p ' '.A ?- -Q ---C3\-v G'Q_-ti-N
Subdivision Name: Lot#:
EXPLANATION: T _.►' 'u 0 ►•1 1�I►U2�
410a • A. . ac $� a _ ' , Or1a -- • 0 a / , •_. Q_ 4
1, . /• MEM . •e • 0_ .I . amu. ; 1 2 1-14( • a• • i.0
OIe\—lCn0.. .braW.eAN(N rr ,..ELs 1ACt- - , .__ . ,J
Signature: )1)1/-/-\
' M` _ Date: -1 '�1 19
Print Name: 1 L e-,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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 804 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 By Route to Records: Date , fj /�j B .
Refund Processed: Date /9- By Z�f: Invoice Processed: Date / By
Permit Canceled: Date fhb? By -01,. - -Tag Added: Date By. 1
1:\Building\Forms\ReyPermitAction_t 0 8.doc