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Permit Support Document City Of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 11 . Request for Permit Action .1 f(in.k I) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503RE d-or. ov TO: CITY OF TIGARD APR 2 7 2020 Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 ''t.`,�llry OF FIGAR Phone: 503-718-2439 Fax: 503-598-1960 aY'igatlitalia *rigard-or.gov FROM: ❑ Owner ❑ Applicant , Contractor ❑ City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) K IA� '(won b R 0 cL Se w L i e_S Mailing Address: ‘7).0 Ec.. aSJ City/State/Zip: �'\d,e _.... el CI tic)+Y q e61/ Z Phone No.: ( .16o) Z I 1 - 6/ d' PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ❑ CANCEL/VOID PERMIT APPLICATION. �. rl ) � 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 #: p L i/\ 2O tq ' OO /172- Site Address or Parcel#: 11 7 C Q S tb l a c i4-‘ PL. T1 Qo 4, 0£ q7 Z LI Project Name: P0.Cce_ 1 ( 1SII-DD000D) Subdivision Name: Lot#: eQ EXPLANATION: I c n 6e.ne p \ CO(�-1-t aC--1E-�c" an� c�vJ &QC IN Cl- i S St.�e S ail a a off,L.L. -e/\ks O Oc )c -Lie loc. e_ C_-F- -&1.Q ob cS '�r,co'or)p -� I`Gl., j cli n o 1c Ie_ eke } ��bcoit.4-poLc �s �'t s � : k 1)ro�e-1- oc girl- j:)W c - G ',I\a . . e Signature: - j/�,�_ Date: 4•/j 6�c / q, Z ow Print Name: � // l p a 1 r Refund Policy 7 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. kG—Fu Ni, AJa T- ,P2o Ce3srT ' (Z) mist°6-c 770 n/S GJ ',�— ce 7/O(-a / e�� 6u-% io i- 75n1°9-4-. 4Q . ���`/1<; Route to Sys Admit': Date By - Route to Records: Date 2)/2O By Refund Processed: Date ,, Bv4 j I nvoice Processed: Date By Permit Canceled: Date J By � Parcel Tag Added: Date By I:\Building\Forms\RegPcrmsrAction_12 518.doc INCITY OF TIGARD RECEIPT }g 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: 11769 SW 129th pl Tigard Site Address: 11769 SW 129TH PL Receipt Number: 427097 - 11/22/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PLM2019-00472 Tub/Shower/Shower Pan 230-0000-43101 $37.53 PLM2019-00472 12%State Surcharge-Plumbing 100-0000-24001 $8.70 PLM2019-00472 Minimum Fee Adjustment-Plumbing 230-0000-43101 $34.97 Total: $81.20 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 5791558 PUBLICUSER32530J11/22/2019 $81.20 Payor: kingplumbing Total Payments: 581.20 Balance Due: $0.00 Page 1 of 1