MMD2022-00002 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 I
11,4 _ Request for Permit Action
I ;,;, ,, l, 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 TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attachA ( case� fee schedule and provide explanation below).
Permit#: M,rLV(/V(,2 QOOO
Site Address or Parcel#:
Project Name: Pia-c1n NAturi,C"Avv'
Subdivision Name: Lot#:
EXPLANATION: ` —UC U Ca.4C. Of N4 P )242.Z— cotDD k
Signature: Date: 11 ti\pv/
Print Name: �CS Lt✓l4Ur
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date AA 22, By pit. Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date 1\1 . , By \)i.1 Parcel Tag Added: Date By
I:\Building\Fomvs\RegPermit A ction_120518.doc