Permit Support Document `l ,E f L.:Li
City of Tigard • COMMUNITY DEVELOPMEN PA TMENT
MAY 2 4 2020
Request for Permit Action
t r 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •www.tigard oi". dgjr('IjNtG [ 'VISION
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 Applicant ❑ Contractor C City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) R1 VQ,45 offne
Mailing Address: )7 I 3,3 W V) t/ �''t°L i� 3
City/State/Zip: 13 V v+C. G!\ 97>C
Phone No.: 90 5 r 6 (4S —G�g- 2
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED(✓):
g. CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUES(attach case fee schedule and r e explanationti below).
r'L
Permit#: ✓"t�' G//c- % Oa cP/
Site Address or Parcel#: 7 4 G SS IA/ tX/t,se."t c.
Project Name: E/ eye) 12,,.0-.,
Subdivision Name: Eld-etA9 4,-,{ iL�rt� Lot#:
EXPLANATION: R c S to�jvn r t4 Vt) G C)J ek^t p ZCv'I
Signature: Date: id"Li
Print Name: OCiti
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
It/I{ O1'IIULi 4Ltt``I.ti
Route to Jys Acirrun: Date By Route to Records: Date 9' /5 by„de
Refund Processed: Date -L/lff- By*4[) Invoice Processed: Date By
Permit Canceled: Date c. ' By Parcel Tag Added: Date By
I:\Building\Forms\RegPennitActiory._,1 51t f/8.doc