Permit Support Document RECEIVED
MAY 14 2020
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
1111 y CITY OF TIGARD
Request for Permit Action BUILDING DIVISION
T I G A Fl D 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 TigardBuildingPermits@tigard-ot.gov
FROM: ❑ Owner Q Applicant ❑ Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) David Weekley Homes
Mailing Address: 1905 NW 169th Place Suite 102
City/State/Zip: Beaverton
Phone No.: 503-213-4415
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
El CANCEL/VOID PERM.0 APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule an a ea ation below).
Permit#: MS 62O00109 J i .24-20 —DO Q 7/_.)
Site Address or Parcel#: 12079 SW Summerbrook Lane •
Project Name:
Subdivision Name: Summerbrook Lot#: 1
EXPLANATION: •lease cancel builidng permit applicaiton-new plan to be built on site
Signature: Date: �j(l 1 4((Print Name: I: Schiedler
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
/cu%— Ia�iC�de
Route to Sys Attain: Date By Route to Records: Date (o 3 -7.0 By
Refund Processed: Date /t1/41- By Invoice Processed: Date n./ gig— By 4/14,
Permit Canceled: Date 4,/;12f1 By Parcel Tag Added: Date By
I:\Building\rums\RegPermitAction_13l51$.doc