Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request 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 3 /2€1
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@ d-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor lty Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/
Pho. o.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
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#: ,.r 1 c r dC%rg-0-066C 7
Site Address or Parcel #: /CY.3r)
Project Name: v /�¢l virv�g
Subdivision Name: / Lot#:
EXPLANATION: G,..e.„fo.,,p Sara„-�t7- dA, e✓✓)✓ /'V/ rj�eu[, A
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Signature: - Date: '4Q1s-/
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 }� By . Route to Records: Date3/Zp/Z By c'
Refund Processed: Date /- B Invoice Processed: Date By
Permit Canceled: Date 3 20) Byl Parcel Tag Added: Date By
l:\Building\Forms\RegPermitAction_t 20ti.doc