Permit Support Document (2) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
"' RequestFEB 3 2020
for Permit Action 1,1
CITY OF TIGARD
TIGARD, 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigaRVW DIVISION
TO: CITY OF TIGARD
Building Divisionill
13125 SW Hall Blvd.,Tigard,OR 97223 3 ,,} /, ii -"
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits tigard-or.gov
FROM: ❑ Owner ❑ Applicant ] Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) UL
Mailing Address: --.1614Gj(,„ 0 l r r C&,,,
City/State/Zip: r _OC O .e‘I O Gam-►0 6
Phone No.: Sj g�_�L ( l
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
„# CANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
E INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: t( 1 .-7 Q (IC? - CXJ\ —(C
Site Address or Parcel #: "7 t O Sid \: vO ��
Project Name: ---P„e . t.at1%-rC As c DC —\Lk hcw
Subdivision Name: Lot#:
EXPLANATION: CjksV- c- (1A in c„..k leci `vS `
Si nature:
g •
o.. MCITY\ cpc _ Date: 1) ( \2d
Print Name: Lcr- , ,My.,\�f`
$.cfund 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. •7,-<, crt) �vG •c77 O r /5 ,
FL/'c7J �7 i,, •P0
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date q 3 2/ B ,
Refund Processed: Date .:s / By Invoice Processed: Date By
Permit Canceled: Date
'?a �; By , � � "Parcel Tag Added: Date ByI:\Building\Forms\RegpermitAction_] 518.doc