Permit Support Document VOID _
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT MAY 4 2.020
IN ir- Request for Permit Action ' y W.
1 , ; , 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 Z1 Applicant ❑ Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) F.;J 'de tle >!.s 1.--LC
Mailing Address: i- 53 /i L E r& 1. P tieL -44,3.
City/State/Zip: 15e01/6viCa--1 G 12 7t7O(
Phone No.: 503 - 61.4 5--
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
® CANCEL/VOID PERMIT APPLICATION.
0 REFUND PERMIT FEES(attach copy of original receipt and provide explanation below).
EL INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: MST C UC S Le./ . ;2019 -- Q0, ---(F-'
Site Address or Parcel#: "75 U1 S tAl t//-
Project Name: E ictije.rt j id,e.-
Subdivision Name: E l d- - f2Q01 G,1,.- Lot#: 1 7
EXPLANATION: P. 1.et b i )n q C.t 4t. -,'j- -ct c-c.- ' l api
Signature: -I Date: 15 /,2 Lt / C P tY
Print Name: ' .P td,; a. c,}y
cJ
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FUR 111 I 11'l I 4,1,_ t IN.i_'y
Route to Sys Admin: Date By Route to Records: Date f /S Zj' By X/
Refund Processed: Date /�� ` By 4/0 Invoice Processed: Date By J
Permit Canceled: Date 4, Lase By c , Parcel Tag Added: Date By
I:\Building\Forms\RegPennitAction_t 51 Woe