Permit Building Division
Request for Permit Action or Refund
City of Tigard
CITY OF TIGARD
5
Permit System Administrator FEB 6
13125 SW Hall Blvd., Tigard, OR 97223 2006
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov CITY
of TlU
FROM: ❑ Owner ® Applicant ❑ Contractor N • .:t ° J DTV1STON
(check one)
Name: HVAC
(Business or Individual)
Mailing Address:
V 0 1 0 City /State /Zip:
af4 /� Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
® CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES.
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: MEC2006 -00072
Site Address or Parcel #: 08840 SW DL ST
Project Name: VERIZON h
Subdivision Name: Lot #:
EXPLANATION: New permit not required. Added to existing mec2005- 00646.
Signature: Date: 2 -6 -06
Dodie Rossetti
Print Name:
Refund Policy
I. The Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80 percent of the permit fee for issued permits prior to any inspection requests.
c) not more than 80 percent of plan review fee when an application is canceled before any plan review effort has been expended.
2. Refunds will be returned to the original Payer in the same method in which payment was received.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date By Rte to Bldg Admin: Date a (o o' B .#
Refund Processed: Date A09 By Invoice Processed: Date By
Permit Canceled: Date a/(,, /O 4, By Parcel Tag Added: Date By
Receipt # Date Method Amount $
I: \Building\ Forms \RegPerniitAction - Bldg.doc 01/20/06