SGN2021-00027 asCity of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT/ 1
11
' Request for Permit Action 72 ,.
TIGARD 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • ww w.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 ErCity Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
,ff. 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 #: ((P1 Zoz,l- O()(2 2 -
Site Address or Parcel #: (Z'-1)"5- Cott4" ANN 91v0 CA ' I* 2 S/ 0/A A O 2 DQ
i
Project Name: fII '1R.C4r1:2.. APV I S cs Pi' 'i 4r,AJ
Subdivision Name: .,..--.., Lot#:
EXPLANATION: ACCtOenr4u..y IN voi e e_D Ftej as 'P- slv,4 " caoe
fln "P- MA O t. OA A GC-4 c.' . ilk. Fees M vc.T7p4-1e0 R Y Z-3 1 r.,op a. our-l-o
.13-2, Wog i34,7-' vie S ) peer%ir- pew- or a i —X B 231. -5-er 56A/261 Zi'G''d .
Signature: Date: y 49 �Zb i/
Print Name: N/KK. ► TU/So
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Dated ( 2.r By,cw
Refund Processed: Date 7/�. B 4 i Invoice Processed: Date By
Permit Canceled: Date 74. /;+a Bye#e Parcel Tag Added: Date By
I:\Building\Forms\RegPemutAction_12051 doc