Permit Support Document (2) 719
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ///0/ 70
11 - " Request for Permit Action
i 1;;A it n 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 •www.ti v --
NOV , 2019
TO: CITY OF TIGARD TIGARD
Division CI- ®, ``-
13125 SW Hall Blvd.,Tigard,OR 97223 gUiLD;�°1C DIVISION
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner \y4Applicant ❑ Contractor El City Staff
Check(✓)one
REFUND OR Name: l j�,,
INVOICE TO: (Business or Individual) (sa S�T- vA e�.1.1 n.9„, ai,•1,\1 c3
Mailing Address: Q (SW \d ay)l0
City/State/Zip: ' y -\an c (use_ cri.?- Th
Phone No.: o:) e;lk45 62L4-01.
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
4 CANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FFFS (attach copy of original receipt and provide explanation below).
El INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: 1J1tC_-D-D 1 00 f59`-3
Site Address or Parcel#: a S k k a- ie,1' ,‘L.QQ, `d ` {
Project Name: ?()1,U\.e, I •1_.e1''J`-t c7 5�+�
Subdivision Name: Cti.Q\Cjf \ eyefEstecins1.404- Lot#: ct Q
EXPLANATION: r \'te tr C ano e k k ea job,
Signature: _ii CU Q C/ Date: ‘tp-si 1�
Print Name: 1�1�Ja1( nil6Yl
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. 977,
57 so 7 y .fro if. 79
io v )__. F 2. °7Ucf' .2.o ``,y
Route to Sys Adrnin: Date By Route to Records: Date q/7/2/ By
Refund Processed: Date//7/7,,7,,&i By — Invoice Processed: Date By
Permit Canceled: Date/MP/p-2j By ,Parcel Tag Added: Date By
I:\Building\Norms\RegPermitAction 1205r8.doc