Permit Support Document lr
RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT SEP 17 2019
Request for Permit Action CITY OF TIGARD
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • z Wce,t1);Xlr i J PING DIVISION
TO: CITY OF TIGARD V 0 I
Building Division 6/3/,c� ,,jet"
13125 SW Hall Blvd.,Tigard,OR 97223 �'
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@atigard-or.gov
FROM: ❑ Owner ❑ Applicant 0 Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) EC Electric
Mailing Address: PO Box 10286
Portland,OR 97296
City/State/Zip:
Phone No.: 503-220-3528
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
❑x CANCEL/VOID PERMIT APPLICATION.
Q REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
C INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: ELC2019-00610
Site Address or Parcel #: 13335 SW Hall Blvd,Tigard,OR 97223
Project Name: City of Tigard 77350-12
Subdivision Name: Lot#:
EXPLANATION: I mixed up the address and scope of work with another permit I needed to pull in the City of Tigard.
k C11-•T5— f ,y/7— — S e-C 2-0/9 - 006,/ . - ,
Signature:
Date: 9/17l19
Print Name: Carrie Maso
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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. •23 % b ter7. .7l 4/6 4 '
• 37 .02.0 ? •`i6 —5�- V7
FOR OFFICE USE ONLY
Route to Sys Admin: Date Q V-4- ot By S,^ Route to Records: Date Ff a7 .=',- By /i
Refund Processed: Date of/3 f, By tali Invoice Processed: Date By
Permit Canceled: Date /d/3///� By =- . arcel Tag Added: Date By
L\Building\Forms\RcyPcrmitAction_11t151fi doc