Permit ' 03/26/2009 17:23 5032230104 PAVELCOMM PAGE 01
RECEN ET
Community Development MAR 2 7 20
�
T 1 t i A RD Request for Permit Action CITY OF TIGARD
BUILDING DIVIS
TO: CITY OF TIGART)
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 K Conttactor El City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Auk or Individual) pav ,1
� C v `/i m
Mailing Address: I to g° 1 U t 1
Cit /State /Zip: V-Manci t 04 q1. 2.O'
Phone No.: 6)5 2:2.3 5
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): 69
CANCEL PERMIT APPLICATION. i 1 V r
REFUND PERMIT FEES (attach receipt, if available). I 1
INVOICE FOR FEES DUE (attach case fee schedule and explain below). O` id. ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). /1 r
•
Permit #: i_.12, 2 — 00 2,0C) , 1 14 O
Site Address or Parcel #: 1 S I 55 ^ 0 ` 002.- !0 a as •
Project Name: )QJ1k7 •OPYUtiy v A CA On S
• Subdivision Name: Lot #: 0 ! r, -
• EXPLANATION: Da 001- d pnj U 9
011'94,
Signature:
_ at_____TiLt j„....t
Date: 2io `0 ly
Print Name: J au rae Po ie
Director 11":1004
1. The D� tat or Ataldmg Official may authorize nc� x fiord of. /*
a) any fee which was erroneously paid or collected.
b) not mote than 80% of the land use application fee when an application is Withdrawn or eaneeled before any review effort has been expended. i
c) not more than 80% of the land use application fee for issued peanie. ,/(
d) not more than 80% oldie building plan review fee when an application is canceled before any plan review effort has been ex ng pennit fee for issued permits pave to any inspection eeque +ta
r
expended.
( ��J l
e) not more than 80% of the b
2. Refunds will be returned to the original Payer in the aurae method in which payment was received. Please allow 1 -2 week for processing refunds. ^ � ��
Rte to Sys Admix: Date A7 a Rtc to Bldg Admin: Date B ,.,,�() ‘,
Refund Processed Date By Invoice Processed: Date By �/ I/ (
Permit Canceled: Date By Parcel Tag Added: Date By
Receipt # Date Method Amount $
I : \Bwlding \Forma\ ResPcmiitAc6on.doc Rev 07 /26/07
1
I
114 CITY OF TIGARD RECEIPT
a
I I • 13125 SW Hall Blvd.. Tigard OR 97223
503.639.4171
T[GAR.D
Receipt Number: 27200500000000003438 - 07/21/2005
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ELR2005 - 00200 [TAX] 8% State Surcharge 100 - 0000 - 207020 $6.00
ELR2005 - 00200 [ELPRMT] ELR Permit 220 - 0000 - 431510 $75.00
Total: $81.00
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
CreditCard TAAA CONV 07/21/2005 $81.00
Payor:
Total Payments: $81.00
Balance Due: $0.00