Permit RECEIVED
IN a
e Community Development MAR - 9 ' "11
TIGARD Request for Permit Action CITY OF TIGARD
BUILDING DIVISION
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 0 City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) 1_,D /L a EL (,ll l y
Mailing Address: / A t 55 `�,) L ` t Lb 5'.
City/State /Zip: A02TL.M},3'b 02. 9 7;P -
Phone No.: 503 (C ',' - 5 5.
• ,
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( V 0 1 r,,, CANCEL PERMIT APPLICATION. � / /O /�� � /�
❑ REFUND PERMIT FEES (attach receipt, if available). 4`(-'
r INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: 1 l 0J j ao to -0003 4 5b30- oho Io-bD037
Site Address or Parcel #: • 7 S (o .w 1.0 u f./L• .L3
Project Name: —e t 'ri )' / 0 E 4- bbL✓ a
Subdivision Name: --- 612%,-0-4,0y 7tA) o5 Lot #: ;N
EXPLANATION: fit) ter OcZtJ t.2 C LJat -t .( rreb D ( cc - Et f., X /4 6 F
P _ik(∎ . ' It HST aotl — ODOgO .
Signature: C
C Date: c5/11//
Print Name: L - t- 11 .)61.f._ ik-b /.l- H -k l
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
c) 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 1 -2 weeks for processing refunds.
FOR. OFFICE USE ONLY
Rte to S s Admin: Date g QTIMINQ P_ jail Rte to Bld. Admin: Date 3 B -1/M.11
Refund Processed: Date //GA B 4.1,M Invoice Processed: Date MN= B 4 4��
Permit Canceled: Date ,3 AWM B A 1►' Parcel Ta: Added: Date B
Receipt # Date Method Amount $
I:\ Building \Corms \RegPermitAction.doc Rev 07/26/07
a CITY OF TIGARD
e ' Buildin g Division
TIGARD 13125 SW Hall Blvd.,Tigard, OR 97223 503.718.2439
INVOICE
TO: Webber Brittany LLC Customer ID: C11 -0001
Attn: John Webber Invoice No.: INV2011- 00011
12155 SW Wildwood St. Invoice Date: 3/10/2011
Portland, OR 97224 Date Due: Upon Receipt .
•
f,Case No: 71 Site Address' • . • - • : Subdivision -Lot # or Project Name Amount Due..
MST2010 - 00037 7865 SW Webber Ln. Brittany Meadows, Lot 36
Building plan review completed,
less $750.00 deposit $163.68
CDC Plan review, RES $46.00
CDC Plan review, RES - LRP $6.00
Erosion Plan Review - COT $28.60
Note: Plan resubmitted on
3/8/2011 under permit number
MST2011- 00040.
•
Invoice Total: $244.28
❑ Please see attached fee schedule for description of fees due.
(Detach and return this portion with payment.)
Case No.: MST2010 -00037 Customer ID: C11 -0001
Site Address: 7865 SW Webber Ln. Invoice No.: INV2011 -00011
•
Project: Brittany Meadows, Lot 36 Invoice Date: 3/10/2011
Date Due: Upon Receipt
Invoice Total: $244.28
Amount Paid: $
Office Note: Forward copy of receipt to Dianna Howse.
Please mail payment to:
City of Tigard, Building Division
Atm: Dianna Howse
13125 SW Hall Blvd.
Tigard, OR 97223
1: \Building \Accounting \Invoice.doc 01/14/2011