Permit Support Document 1
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT f(///t f KOTr--
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Request for Permit Action
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TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ity Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE AKE 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#: ft-/ 2c)/' —601i0
Site Address or Parcel#: Ii Sit l; ;f i.,.) A)„,,,,A - nvLX
Project Name: , f i �/
Subdivision Name: Lot#:
EXPLANATION: (t-zefc.A ,1","i' ,ki z'd✓chr __27-71-- L.u- sX74-�^n.►n .(
ei Air...) Q`17-er,e0- IAr. Ik 3 .:,,c-vie/ k7L � ,:>[Lt/t1.vL-I >�i y-t /L.).5-t./ 7
c:4-ii. . tiltvr",y` r"---.o 1717-G/ I(/ ✓5 G/�,' /Ae-Aii d �,Z0 1 e( col'ftti,
Signature: Date: 6/f4,/iy
Print Name: am..pe, . l 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 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 (A /!• qtr By d'I . Route to Records: Date /1 / /9 B
Refund Processed: Date • By, j/ Invoice Processed: Date By
Permit Canceled: Date Ii' i i.i By '; -arcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1 51 .doc