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Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT \/ Request for Permit ActionAZet2,0 TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • w ww.tigard-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPcrauts@tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor ja 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 (✓): Er. 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#: Z e•alGid,(] ^ 000.7S Site Address or Parcel #: 1 �1(�^ $Lt, ce- cL(.s Project Name: (,-r-, tmfAhR f Subdivision Name: // Lot#: ^ EXPLANATION: 5 tAde.P GJKf C 7S 2 l i .So✓Y�. Signature: Date: 02 7/W2-CS Print Name: (1y l! Kefirnd 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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°/i 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. Route to Sys Admin: Date ,'Z l ?-f7 By Route to Records: Date n_ B Refund Processed: Date /1,{,/¢ By / Invoice Processed: Date B Permit Canceled: Date 3/'zrJ�'� By ¢- ' Parcel Tag Added: Date By I:\Budding\Forms\RegPennit5ction_ 0518:doc