Permit Support Document (17) V 0 I D
CitCOMMUNITY DEVELOPMENT o f Tigard • DEPARTMENT
, in 4
III Request for Permit Action
i I G A R I-) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www tigard or gov,
tit TO: CITY OF TIGAR � ..
D
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223 ,,,
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPertx%ts@tigard=drgov
FROM: ❑ Owner ❑ Applicant D Contractor , J 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 (1):
j 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#: W5010/ 1 -60D .
Site Address or Parcel#: 7l 41 ir. ¶ 41 (1--U-fr(
Project Name: ' v`''V'i Z.P1 ,;
Subdivision Name: Lot#: ----
EXPLANATION:
--EXPLANATION: L C Vro,,7-ce Cb 1- e't‘ f r F-"//
IzSfsPer�'ti ( P1/1-5dz-.- tt-1411 1&-,- 1 5 5.010 --. OR-. .
Signature: /i - , ' D ate: 7//�9
Print Name: .,t ((r_ i/,pti<tvairA'
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 / 1 By TA Route to Records: Date ,../7/ /7 B of '✓ -
Refund Processed: Date N/ ' By it . nvoice Processed: Date By
Permit Canceled: Date ?J /9 Byer 1— Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1 05 :.doc