Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
'PI I " Request Permit Action
I I l. ; A l: I) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov
TO: CITY OF TIGARD V ® I D,
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223 �/Z .//_3
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) / /4-
4
Mailing Address: (((
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( ✓):
CANCEL /VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
El REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: lr r2. 90 / ° D - 6C) / a--4
Site Address or Parcel #: / 3 5 / , o a g Fi} a / 2 / - j 7 / O
Project Name: H 0 4 - l '2. .. 5S ..L..c) S6_,. 0 (.r - 5
Subdivision Name: Lot #:
EXPLANATION: �f CLf r Ts APPLE f7 C12 1 2- ti alo/ -aO / 9 3.
l \o `Jo c- his Di&.€ .
Signature: Cd.-Th agia_.-14A—Q-kDate: 7 79-7-// 3
Print Name: 0 8 I t Rr)6 frt S Kl
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
e) not more that' 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 2 -4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date 7 /a2- / By • Rte to Bldg Admin: Date 2 2.r /3 By .i''r
Refund Processed: Date iVAI B .174 Invoice Processed: Date By
Permit Canceled: Date 26.-/,3 By /r. Parcel Tag Added: Date By
Receipt # Date J Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 05/25/2012