Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
114 Request for Permit Action
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD f
Building Division C/
13125 SW Hall Blvd.,Tigard,OR 97223 . /e/2d
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPe is@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor Q.EityStaff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTI FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
0 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#: ,L O3 j)—X k)i,
Site Address or Parcel#: 6c,5-6 S-4 r I,ki.,1 LA ep,i /1 D
Project Name: _;_("' r,(i inept,c- 2
Subdivision Name: Lot#: ----
EXPLANATION: 6-eQ,t-r,t fc..-v r„: ,lv C--rewt i=AS Are-Lsf. ./ i•-e) .16-
inl S—I-Je- •N) 7h771- i. - l�oe.hr)-r)-C.Y.)0 i y
Signature: ���-- Date: /2-r 5-7?. ,
ei�
Print Name: ,_,
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 )/ --,}1J By '� Route to Records: Date , ,2?. B !4
Refund Processed: Date NY By Invoice Processed: Date By
Permit Canceled: Date?j 24 her By ,.,, "Parcel Tag Added: Date By
I:\Building\Forms\RegPemvtAction_ 2051 .doc