Loading...
Permit Support Document Cityyof . C.(7i41N1UNI'I'Y DEVI:i.OPMRNT DEPARTMENT 1111 r p/3 jibKew__ Request for Permit Action TIGARD 13125 SW Hall Blvd. • Tigard,Oregon 97223 . 503-718-2439 •www.t'g:ird or.guv TO: CITY OF TIGARD RECEIVhD Building Division SEP 2 3 2019 13125 SW Hall Blvd.,Tigard,OR 97223 TIGARD Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermit--AtAt 6'9isION FROM: ❑ Owner t►!' Applicant 14 Contractor ❑ City Staff Check(✓)one , REFUND OR Name: \ 1\1 V�t� INVOICE TO: (Business or Individual) c-}0,-1Ak U ( (' ; iNe)ire Mailing Address: iot ipcki\€ City/State/Zip: 96(. 'iO4\o, , 044—ttT 9'I07 I 7 Phone No.: �" 7 - 6 1©, — r ✓4 , PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): Vd 6 4 CANCEL/VOID PERMIT APPLICATION. 1_/) / /? —0 ° 3 '77 J REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). 111 INVOICE FOR FEES DUE (attach caseca fee schedule and provide explanation below). Permit#: AP L-0 Site Address or Parcel#: \ , ti` ln.n 2-2- Project Name: SG\ Subdivision Name: Lot#: EXPLANATION: a) ( G,' \ w1 Oki& \ -- � / G� /9 _ �f� 3s _ Signature: ., Date: C \\Pt, \ TA Print Name: CK tt.9 Refund Policy 1. The city's Community Development Director,Building Official or City Engineer may authorise the refund of: • Any fee which was erroneously paid or collected. • Not more than 80"/o of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. 7•Z-s r �^ ( 61) 1"/ 70 - r7�' �� - / 7 'ffff `ff FOR OFFICE USE ONLY Route to Sys Admin: Date q /��� By l Route to Records: Date £ 17 - / By .41 Refund Processed: Dater/3 7 By ft/ Invoice Processed: Date By Permit Canceled: Date/A/ B•,�.�. Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_I 51 .doc