Permit Support Document (2) V ID
city of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
111 � +� ///07424
Request for Permit Action q ct on
T 1 A R DD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD RECEIVED
Building Division DEC 312019
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPerrd. f;' aDP4t SD
ON
FROM: ❑ Owner ❑ Applicant 0 Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) ` , }2 r n ctv 2()
Mailing Address: SC -72 1 lQ ,
City/State/Zip: I U 5i'boyz.), vCZ cy- (a
Phone No.: t�-
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
4-1110
CANCEL/VOID PERMIT APPLICATION.
VA REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
II INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit #: LC O 9 °'CbiA-)
Site Address or Parcel #: j to b(90 St .) Av.e. - T`tei a 17,Q v(Z.q7
Project Name: C(I3 I>(optk-{ M 4 S
Subdivision Name: Lot#:
EXPLANATION: m ��� l��l .6004,0') pUlLS(Doianus1 Z.C2.d ( — fd''-7 r if t
Signature: Date: f cD-I 0 I l c/
Print Name:
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. / *2-0
FOR OFFICE USE ONLY
Route to Sys Admin: Date trni I y By '7" Route to Records: Date 9/3,y/ By /
Refund Processed: Date ///7/74 By ,'.L, Invoice Processed: Date By
Permit Canceled: Date Op/24,. By it-, Parcel Tag Added: Date By
1:\Building\Forms\RegPermitAction_ 2051 .doc