Permit o VOI Community Development Re uest for Permit Action
TIGARD
TO: CITY OF TIGARD
Building Division Services Supervisor .
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner p Applicant ❑ Contractor EF<CrStaff
(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.
❑ REFUND PERMIT FEES (attach copy of original receipt).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: Et C_ go I e c)O I L( f
Site Address or Parcel #: /6 / CfS 6 - 7 r{f 74(y
Project Name: O r2 '
P
Subdivision Name: • __--- Lot #:
EXPLANATION: nree„- e- e— r-) , J r liv e r, izGL • Sk UI
G\ 4 v_ bto /ki cuo Tz r-2 P • NP,) pe 1E 1-ie ozo t x- 0.-_f
Signature: /L"� Date: 1) /� /1.
Print Name: e3rQn iceig_ pJ et
Policy
Refund Poli _ (,(�
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 the original Payer in the same method in which payment was received. Please allow 2 -4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date 7A M' B >I Rte to Bid: Admin: Dated' B ./'
Refund Processed: Date - By �ss� Invoice Processed: Date By
Permit Canceled: Date 3 /S //Z B p• arcel Tag Added: Date By
Receipt # Date Method Amount $
I: \Building \Forms \RegPemutAction.doc Rev 04/26/2011