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
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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#:
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EXPLANATION: I c n 6e.ne p \ CO(�-1-t aC--1E-�c" an� c�vJ &QC
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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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
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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
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