Permit 11 Building Division
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Request for Permit Action
7IGARD
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TO: CITY OF TIGARD
Permit System Administrator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Si II Mailing Address:
<SPA 7 )604 City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
® CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit # : ELC2007 -00131
Site Address or Parcel # : 10700 SW Black Diamond Wy
Project Name: Perry
Subdivision Name: Lot # :
EXPLANATION: Created it as a stand alone when it is part of the Master.
Sr & /VSi �Oo 7 .
" Date: 3/5/07
Signature: ✓ 4,0 4.7^_r_..
Dodie Rossetti
Print Name:
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
c) not more than 8C% of the building plan review fee when an application is canceled before any plan review effort has been expended.
d) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be retumed to the original Payer in the same method in which payment was received. Please allow 1 - weeks for processing refunds.
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Refund Processed: Date N/' By,( Invoice Processed: Date By
Permit Canceled: Date' /14 7 By, - Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \ReqPermitAction.doc Rev 05/24/06