Permit Support Document (2) .
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT R CEIVED
1 . Request for Permit Action MAR 1 12020
1 ; , t i , 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • i ( F TIGARD
Q� ul r, nlvlSION
TO: CITY OF TIGARD r� 9
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Building Division 3/Z
• 13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: El Owner a Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) C D CL-t
Mailing Address: _15 7 co; -V; A." Ceit\keAr ' )v'. r
r t 2�
City/State/Zip: —TZ�c,.,,AJ <-e. 9---1 2-2-3
Phone No.: 6l1 l - 20 S--y 2 2
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
[l CANCEL/VOID PERMIT APPLICATION.
R/ 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#: t..G 20 tcl -00 crSGi 9
Site Address or Parcel #: 1 I0S S\,. \--VA.mQ-p t ti,n 1 5c4-,--A r OZ °l 12.23
Project Name: Y,,c,I.5 `�t z,�S
Subdivision Name: Lot#: t 1
EXPLANATION: �-eirr".A" oc.S +Mk. u1U U . �vr_1.ti� e(
;.„G ik. a\v--Q.o.A,) VAAN\LA O • - ' 60- iec,20 -vv,,vy .,
Signature: Date: 3/j/ 20
Print Name: ::7-a.,,c
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. .2-7- (o V /12. 7/ //�
s s.
— %(G' '3 7 -' 5D, 9 l
Route to Sys Admin: Date By Route to Records: Date y%/3/'l j By„epee'Refund Processed: Date_3/zj/'?v B Invoice Processed: Date // By
Permit Canceled: Date.:,3/'Z[7/7,,, By Parcel Tag Added: Date By
I:\Building\Farms\Reg1'etmitAction_120518.doc