Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 I
71
■ r Request Permit Action
I t G A R I) 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: n Owner ❑ Applicant ❑ Contractor gIDCity 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):
# 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#: EZC 09,.0/I/- 0 0 Vg3
Site Address or Parcel#: /WO 7e JJ &CC-G-L. or p f7 /n/ /O
Project Name:
Subdivision Name: Lot#:
EXPLANATION: CZE - /A/ Ef2,e4,e — SEE' EZC.2-to/Y- opt-pig,
/YOTE-.' /✓b ",20,1-16,-770^/ rer L 7;3'15 ,E721"1/7 elS s97 fel "vi
ge- (S ,7 7"a f .u6/y/r ii vt - &zc v?$7 y— DD yyy —
Signature: Date: cFAy,/y
Print Name: .(4-n/n/} // is€
Refund Policy
1. The Community Development Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80%of the land use application fee for issued permits.
d) not more than 80%of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80%of the building permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date 13) Ric to lildg.Adman: Date j= /y /y By i'.
Refund Processed: Date /1/i/q By Invoice Processed: Date By
Permit Canceled: Date //y!/y By Parcel Tag Added: Date By
Receipt# Date Method _ Amount$
I:\Building\Forms\RegPermitAction_062614.doc