Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ® I 0
INI " Request Permit Action 4.203
TIGARD 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 ❑ City Staff
(check one)
REFUND OR Name: /
INVOICE TO: (Business or Individual)
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).
❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: r a_p (3•- O n SZo 7
Site Address or Parcel #: (0)(x St,)- /v(Qr- - Aa,1 •
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Project Name: W-6.)
Subdivision Name: Lot #: —
EXPLANATION: Cd'ea perrnrt' i\N error, arc( N ' f r /, '"e-._
i -. a_I 0 Am#1 4. __IV + EX. Lk - . i L , 0 —00S - ,
Signature: T _ - MO Date: 9/ /
3
Print Name: Qrj,.C � ,t4 ri
Refund Policy (N
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 m 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 l�ia B Ati Rte to Bldg Admin: Date /� /.3 /3 By i
Refund Processed: Date A/ el- By ti Invoice Processed: Date By
Permit Canceled: Date /.2/3//j By . ' � Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 05/25/2012