Permit Support Document nit
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT II
Request for Permit Action / 42.`' 40
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@tigard-o .gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ity Staff
Check(i)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
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#: 62_If4C1f) S l O.-
Site Address or Parcel#: 7mod ,,
Project Name: `�,'j' "�l� a /� tckli
Subdivision Name: Lot#:
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Signature: C S� a e: 5���-7/ j
Print Name:
Refund Policy
1. The dty'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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 7 7/ By .T, Route to Records: Date /&JJZC Ij O
Refund Processed: Date n/ �¢ B ,i Invoice Processed: Date ` By
Permit Canceled: Date � j/2ll By4l(' Parcel Tag Added: Date By
1:\Building\Fors\RegPemutAction_ 051 .doc