MIS2015-00003 • CityINty of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT f
Request for Permit Action ���z /, e-'
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-or.gov
FROM: ❑ Owner I I Applicant Contractor 7 City Staff
Check(✓)one
REFUND OR Name: N/A
INVOICE TO: (Business or Individual)
Mailing Address: N/A
City/State/Zip: N/A
Phone No.: N/A
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
}X CANCEL/VOID PERMIT APPLICATION.
X TRANSFER REFUND PERMIT FEES (attach copy of original receipt and provide
explanation below).
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
I I REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: MIS2015-00003
Site Address or Parcel #: 6911 SW Oak Street,Tigard, OR 97223
Project Name: Sarvay
•
Subdivision Name: N/A Lot #: N/A
EXPLANATION: Case was mistakenly created as an MIS type,when it should be a ZAL type.
Please cancel MIS2015-00003, and transfer $718 from MIS2015-00003 to ZAL2015-00002.
•
•
Signature: �. 06/I Date: 11/18/15
Print Name: Lina Smith
Refund Policy
1. The city's Community Development Director,Building Official or City 1 nginecr may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Dat y,2 t' /S B;f:PAIT
/ .ts1Cea2+—$efiuui-Processed: Date /1-/.2-41/e5 14' A, 1 Invoice Processed: Date By 1
I I Permit Canceled: Date/L/L%!/.S By •! • isrcel Tag Added: Date By j
1:\Building\Forms\RegPcrmitAction_093314.doc