Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEN1/ 0 1
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Request for Permit Action Vzorw 00
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
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits_@t/igard-or.gov
FROM: ❑ Owner El ❑am Applicant ❑ Contractor ity Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.•
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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#: alak)— 70
Site Address or Parcel#: // /tj) S&) -7 '`,fzrr
Project Name: "7 /-61
Subdivision Name: Lot#:
EXPLANATION: �� >-
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Signature: � Date: /3/ 0
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ONI.I
Route to Sys Admin: Date p/z) By ,Q./; Route to Records: Date {j 1120 By tic
Refund Processed: Date /►/' d By 4#0 Invoice Processed: Date By
Permit Canceled: Date / o By - Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction 1205 doc