Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 0
./zs/y
= . r Request Permit Action REcepa,TIGARD 13125 SW Hall Blvd. • Ti and, Ore on 97223 • 503.718.2439 • www.t $ n
'10: CITY OF TIGARD
MAR 102014
Building Division Services Supervisor CIT Y OF TI RD
13125 SW Hall Blvd.,Tigard,OR 97223 BUILDING Dl�-GA
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov ON
FROM: ❑ Owner ❑ Applicant ❑ Contractor 10 City Staff
(check one)
REFUND OR Name: tv
INVOICE TO: (Business or Individual) //.Mailing Address: t
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
MCANCEL/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#: 101"-aC 11-1 OC)o 30
Site Address or Parcel#: 1-)3 t LLp t3 Po NT 4-0
Project Name: (\Q-Li ,,J C oTT:t 3 14 s 6/1-TS No. LeT I I�-
Subdivision Name: Lot#:
EXPLANATION: to Q l+T� 1-012,5 .) f TYPf 1 ev2-kcle- •
Ss:
1\151-8014- 00o a-9 oC.02..Ao l -oco 18
Signature: Date: 3 l o/i 4/
Print Name: lam E R C , /4-.D.41-111/44 5 k-0
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b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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%'o 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.
1 OR OI 11(.1. 1 sI. 0\11
Rte to S s Admin: Date, rfaignrs1WVI Rte to Bld:Admin: Date ��' B
Refund Processed: Date/V131FMQM%!E Invoice Processed: Date B
Permit Canceled: Date Z$' /y By Parcel Tag Added: Date By
Receipt# Date Method Amount$
I:\Building\Forms\RegPemvtAction.doc Rev 05/25/2012