Permit Support Document (2) RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT MAR 1 0 202U
3. Re uest for Permit Action CITY Of. taRHp
q BUILDING DIVISION
'r I G A It D 13125 SW Hall Blvd. •Tigard,Oregon 97223 . 503-718-2439 •www.tigard-or.gov
TO: CITY OF TIGARD v fl
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 3/ /2
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@atigard-or.gov
FROM: ❑ Owner (Applicant ErContractor ❑ City Staff
Check(✓)one
REFUND OR Name: , i + 11 G
INVOICE TO: (Business or lndividuaq Vt//
Mailing Address: ?' a 5 1 J1
City/State/Zip: - Y O Y k AAA 64 I ( 11 d Itp
Phone No.: 6 o?j• ? 3• c601
PI RASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
►: CANCEL/VOID PERMIT APPLICATION.
A 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#: i l l et, d"0 v i '" O 0 ` t g
Site Address or Parcel#: i i ( 4 5 Gi, 1 ,
Project Name: t I a
Subdivision Name: Lot#:
•
EXPLANATION: ei 1 ( 1 I) i
tip
Signature: jk) Date: ' 3''0 • '10030
Print Name: I 61 s h Li 1}-Zm
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. /1,
7 , er'd - 702•Gi72 02,
is fv
o jd f . 6%
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date 9/ 71 By
Refund Processed: Date_3/2e/ 7 By ft Invoice Processed: Date By
2.
Permit Canceled: Date ,e1 '� By •"jr Parcel Tag Added: Date By
_1:\Building\Forms\RegPcnnitAction 20518. oc