Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
IRequest for Permit Action
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 TigardBuildingPertnits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ix 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 OID PERMIT APPLICATION.
❑ ND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: ,.1ST2O2O — 0.0O7O
Site Address or Parcel#: / //GO Sil // W ,
Project Name:
Subdivision Name: IDOLt/CC7r✓ /+T /4/rt7L ml /2'DGtf Lot#:
EXPLANATION: 01 1 ) /(/ 6 '2 ar" POW/frig M'6T2o20-Gb0 6?
Signature: / Date: D3-if-7 210
Print Name: 7da/a 4'/dana%'
Refund Policy V
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: Date /j Zd
Refund Processed: Date ,,/,4 B y�, Invoice Processed: Date By
Permit Canceled: Date ,I i/ Zr,. By4'/ Parcel Tag Added: Date By
i:\Building\Forms\RegPermitAction_126518. oc