ADJ2020-00011 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Vo 1 b
= ' Request for Permit Action 3/1/21
13125 SW Hall Blvd. • 'Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE_ ACTION FOR THE ITEMS) CHECKED(✓):
CANCEL/ OID PERMIT APPLICATION.
PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: ADJ2020-00011
Site Address or Parcel#: 6960 SW Clinton St
Project Name: Clinton Street Mixed Use
Subdivision Name: Lot#:
EXPLANATION: In the Tigard Tirangle,multiple adjustments are allowed under one case.
See AD12020-00010
Signature: Ay,., Date: 5/13/20
Print Name: Agnes Lindor
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• Not more than 80%of the application or plan review,fee when an application is withdrawn or canceled before review effort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 U5 postal service.
3. Please allow 3-4 weeks for processing refund requests.
• ' OFFICE USE ONLY
Route to Sys Admin: Date B Route to Records: Date B
Refund Processed: Date By Invoice Processed: I Date B
Permit Canceled: Date B Parcel Ta Added: Date B
I:\Building\Forms\RegPemn Action_1 0 8.doc