Permit Support Document Community Development V 0 I
TIGARD Request for Permit Action /0/2-// 2- xbr
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 ® City 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 (
® CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: BUP2012 -00177
Site Address or Parcel #: 11190 SW 125t P1
Project Name: Smith
Subdivision Name: Lot #:
EXPLANATION: Created in error - should have been an MST Permit /`1Sj o2Q/a Doo�3a
Signature: t Date: 9/11/12
Shirley Treat
Print Name:
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b) not more than 80% of the land use application fcc when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fcc for issued permits.
d) not more than 80% of the building plan review fcc when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fcc 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 Sys Admin: Date By Rte to Bldg Admin: Date /0/2// Z By 4P
Refund Processed: Date ii/ /f}- By Invoice Processed: Date By
Permit Canceled: Date / ' , /L /jZ By .t-1. Parcel Tag Added: Date By
Receipt # Date Method Amount $
l:\ Building \Dorms \RegPcrmiv \cuon.doc Rev 07/26/07