Permit Building Division
iii+ ri, ± ,l�l. + Request for Permit Action or Refund
City of Tigard
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)
Name: (ALA)
(Business or Individual)
V0 10 Mailing Address:
J &9-/YAlE-- City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (/):
8 CANCEL PERMIT APPLICATION.
REFUND PERMIT FEES.
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: j J ? 2.00(a — 0 C) t
Site Address or Parcel #: StiSS G t J S6-01,to i i O a
Project Name: I�{� Ip,& p (V �,
Subdivision Name: Lot #:
EXPLANATION: (' )LQ te_ jJOu,t Lrtcii
\n ck,tA 9 U.P_D/Y\ Cc 1pflAintj
. _w • ' !I Ii.. / , . .4 PA Uh^ 001 �e
Signature: Date: y�e/ D�j
Print Name: Refund Policy
1. 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 L / a• dL By Is Rte to Bldg Admin: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date By Parcel Tag Added: Date _ By
Receipt # Date Method Amount $
l:\ Building\Forms\RegPermitAction- Bldg.doc 01/20/06