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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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