Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTVT 0"fl L
Request for Permit Action a/09 „,4 "
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division A10\5
13125 SW Hall Blvd.,Tigard,OR 97223 PUG
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: n Owner ❑ Applicant ❑ Contractor '5 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):
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#: .7 l•czo C, • Uco.0 .
Site Address or Parcel#: `a 5-75— rjGi/ 1,0606? s
Project Name: au 4/ /err_ ` A J
Subdivision Name: Lot#: ---
EXPLANATION:
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Signature: ,/ '
2jfy Date: j7/5�/5
Print Name: �,/t n/I14/6w4-f7•/'
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 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 S s Admin: Date ; zim :, rim Route to Records: Date ' "i'
Refund Processed: Date N .4 : Invoice Processed: Date By
Permit Canceled: Date/0/37 J/ ByJ"f Parcel Tag Added: Date By
1:\Building\Forms\RegPernutAction_ 18.do c