Permit Support Document REc
°\IED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT OCi 2 $ 20\9
D
_ Request for Permit Action c\-1N NGON s10N
I.l G A R CD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tigard- btu
TO: CITY OF TIGARD ‘,/ 0 1 D
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 /0? xe
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 4 j'(-J�v^ tg,C_ E 1 �G L iz, 4 L i c^./
Mailing Address: /��1:2 )pV � g I✓ P . /7
City/State/Zip: WODDLAN p (... a, 9/.‘7 4-
Phone No.: 36 0 2. Z..,. S t6 e 2.6
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
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#: L.r &Z O t ai D D S' Z�
Site Address or Parcel#: 7 � a S/�l�Toiy Q, {�a. K 1, 0
Project Name: L G( iT G 1- - ,F.DX,
Subdivision Name: Lot#:
EXPLANATION: o f u.,,A 5 V Lie-y SLD L..? T C)
34. g r 0 y f• IL 3/4&i. LJL. C...0r t,c..C> No-- mi:LT
7 4' a_ /3r try ,ca.4t,c.,f . _10.z c...DA j ?,4.4,.k...i..
Signature: 4 ern /4,‹ Date: _. .w — Z£ — / 9
Print Name: L,to
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. (D/ u/ 3 S 7
/ (c G 3
FOR OFFICE i-SE ONLY"
Route to Sys Admin: Date By Route to Records: Datef_r 2J By .. 0
Refund Processed: Date j/// ( ' B .,. Invoice Processed: Date By
Permit Canceled: Date /f/y/ i f By• Parcel Tag Added: Date By
I:\Building\Forms\ReyPermitAction_l 5 doc