Permit Support Document Building D i v i s i o n -
All Request for Permit Action or Refu
�aY
City of Tigard APR 2 0 2006
TO: CITY OF TIGARD, BUILDING OFFICIAL CITY (iF I lUI .KL)
13125 SW Hall Blvd., Tigard, OR 97223 BUILD1N( T)T JS!ON
Phone: 503.639.4171 Fax: 503.598.1960
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
(check one)
Name:
(Business or Individual)
V 0 1 ® Mailing Address:
,Jft"/A//fC City /State /Zip:
' Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
® CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES.
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: ELC2005 -00957
Site Address or Parcel #:
Project Name: HOLLISTER
Subdivision Name: WASHINGTON SQUARE Lot #:
EXPLANATION: Replaced by Permit: ELC2006- 10096.
Signature: �Q�,Cc,�c Date: 4/20/2006
Dodie Rossetti
Print Name:
Refund Policy
I 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 retumed to the original Payee in the same method in which payment was received.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date (/ o2D Gig Bye 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 $
I: \Building \Forms \ReqPermitAction 09 -19 -05 doe