Permit Community D evelopment
TIGARD Request for Permit Action
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard- or.gov
FROM: n Owner ❑ Applicant n Contractor ity 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):
CANCEL PERMIT APPLICATION.
n REFUND PERMIT FEES (attach receipt, if available).
INVOICE FOR FEES DUE (attach case fee schedule and explain below). /1// 4//// 0/
n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: C-- < -20 //— 0C
Site Address or Parcel #: G Q . , btu aciU S lvyy / / £ r o2CJ J
Project Name: e .t4/ t 5*
Subdivision Name: Lot #:
EXPLANATION: ( - Q Gt -- - t - i N 2 v Car: ec,r - nom
Skcn4tcit ke4)/ 9 (A) Gw %= { •=9 — QDa `2 7
Signature: t " -- Date: / 0 /�/i
Print Name: 40(731•10k o , cx a ,� -
5�
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended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
d) not more than SO% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building penrut fee for issued permits prior to any inspection requests
2 Refunds will be returned to the original Payer in the same method in which payment was received Please allow 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date v ; p B _ Rte to Bid: AD' : Admin: Date f / ` fZS
_ '
Refund Processed. Date ^/ B r Invoice Processed: Date B
Permit Canceled: Date /Ma B (4 Parcel Ta. Added: Date B
Receipt # Date Method Amount $
I \Building \ Forms \RegPermitActton doc Rev 07/26/07