Permit Support Document S. .
. .
RECEIVED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT MAY 2 9 2019
C OF TIGARD
Request for Permit Action BUIITYLDING DIVISION
TIGARD 13125 SW Hall Blvd. • Tigard,Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARDI
Building Division vp. I a
13125 SW Hall Blvd.,Tigard,OR 97223 er"
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@ti d or.gov
FROM: El Owner Ti Applicant 2 Contractor 0 City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 0 aii3,n) 1,4,10)f.
Mailing Address: 11205g , 111--ekkl MUM)
— slAl-ic Ai CR
City/State/Zip: 1\44,06Uitt4e j CR C1222
Phone No.: (-775-10.2_0 _
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (I):
CANCEL/VOID PERMIT APPLICATION.
Z REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
[I] INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: REL 2-0 (00>41 6
Site Address or Parcel #: 2 t U 00 2,1 LI--
Project Name: 0 6/1
Subdivision Name: VI MM./1Y: 1-617601) Lot #: 12-,
L.
EXPIVION: „-.1-, d awl '6, 1 tow if 10 c roX —61, mOrtf-,
Pnt-t, m,t , 0), witio r tel,&,
1D. cL(XYtt-r:Ym... \im,t90/, .1.4' p GLA,NortZ-e r i nit' s
1:-Nt-t -442(2_&QV P -'yf-D P , , 0 1 5 ce: H 6-- e- 249/ c----th)I f 7 I/-
Signature: TAIN, 1-
0 Date: \'2.61 tq
Print Name: OMV 'j,tLS
Refund Policy
1. The city's Community Development Director,Building()fficial or City 1:xigineer 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• Not more than 80%of the application or plan review fee when an application i,ti withdrawn or canceled before review effort
has been expended.
• Not more than 8D%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.
9 0 , cry le cro ez)
....
lop
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date F1,-1 7 : B 1
Refund Processed: Date 17,1-/ty By „dey- Invoice Processed: Date By
Permit Canceled: Date 1:4)-hy By A../9 - Parcel Tag Added: Date By
l:\Building\Forms\ReciPennitAction_110518.doe