Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
1 a Request Permit Action % /-g /Ag 'o`
T l G A,IR F) 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 U' 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 (1):
E 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 #: PO L.L.P (* / 3 - rx� a 3 5
Site Address or Parcel #: / d >v h 1 Ly
Project Name: tJ 1 I rt L - 47" A HP Ti¢T /fi0 N)
Subdivision Name: Lot #:
EXPLANATION: 1 p LA ( 1 A.--,---E_ PE 21`f 1 r EE 6-Lko 9a ! 3 - Go `
�, 3
Signature: , . , .. j � , Date: if ?-7// 3
Print Name: c66 f_ . 4 j..1.111 `� �, ( 11
Refund Policy
1. The Director or Building Official may authonze 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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 pnor to any inspection requests.
2 Refunds will be returned to the onginal 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 / ! . ENE , / '3 Rte to Bld: Admin: Date4247Z l B , ff �
Refund Processed: Date By ddb' Invoice Processed: Date By
Permit Canceled: Date Jam' /j3 By t "•• Parcel Tag Added: Date By
Receipt # Date Method Amount $
l: \ Building \Forms \RegPemvtAction.doc Rev 05/25/2012