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Permit
VO I D . . Community Development 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: Owner ❑ Applicant ❑ Contractor n City Staff (check one) REFUND OR Name: INVOICE TO: (Business or Individual) V\ S -j 3C ` C Mailing Address: /t Z., 7 SLR G j / l4 4 tt.e 5 • City /State /Zip: ge 051,j 7 C O L Phone No.: So $ 5 7- 7 S 3 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (•): CANCEL PERMIT APPLICATION. 77Z1A S FeR_ SE ES 7 ❑ REFUND PERMIT FEES (attach receipt, if available). �_ 111 INVOICE FOR FEES DUE (attach case fee schedule and explain below). 1 ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). (v Permit #: o4 // 00 - eD Al—sT / / Site Address or Parcel #: 1 50Z7 (4 >/p- PL. Project Name: .l li VJIZAN /Y17 Ak r /()f 7 Subdivision Name: /1—y - f,\l I)/\l j1f Nd ? Lot #: ' EXPLANATION: Po c{ .e at.-( ( L© 'i 7 G/ /141 , 5 1-0 5/7 a ; (i/ A)Cg r V, e (...) P bv- d-. O VA "i 7 A_ /�} •�- Signature: Date: ((' ( 7' ( ( ' Print Name: t' ),./t / c, S64, 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 b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 80% 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 permit fee for issued permits prior to any inspection requests. 2. Refunds will be returned to die 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 amain B -"AM Rte to Bld • Admin: Date / / B lwit`� Refund Processed: Date �Z n / By Invoice Processed: Date By Permit Canceled: Date / /d / By a: T. Parcel Tag Added: Date By Receipt # Date Method Amount $ I: \ Building \Forms \RegPermitAction.doc Rev 07/26/07