Permit 114 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT` ® 1
a. " Re uest Permit Action �19z3 /3
T G A It D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ity Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEAS TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: E( 0/3--a)cf96
Site Address or Parcel#: Lt llo g,J. (.i- /4"'T`
Project Name: Fa.',jj 4p-4 4 S'e/wx I
Subdivision Name: -- Lot#:
EXPLANATION: _ v 'O G./'cc _ - `- e' r
add,7G'1d / c,i-cz,v sties v i-e- i ,,,,e4.6/ 7, 17-44-C-A0/3— dc),? .?,5
Signature: _ _ g ate: /�t///3
l` -
Print Name: B rziA(),-- Tv.,-,, _
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b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 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 2-4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date ! nu' B Rte to Bld. Admin: Date %,,,Y�M B g T
Refund Processed: Date `J B tfyia Invoice Processed: Date B
Permit Canceled: Date 9/23 /3 By 'fi aAlm. Parcel Tag Added: Date • By
Receipt# Date Method Amount$
I:\Building\Forms\RegPermitAction.doc Rev 05/25/2012