Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0 I 0
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r Request Permit Action
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.:
PLEA :AI r A :. ACTION FOR THE ITEM(S) CHECKED (1):
Et ANC OID PERMIT APPLICATION.
M I ND 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#: M A011t—605/y
Site Address or Parcel#: gq'td SA/ FrCtth V
Project Name: ,i/�
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Subdivision Name: "7-66.),>) Q. 14 Tac1c Lot#: p25-
EXPLANATION: C ->r pew-v1).1 f;v Gf'>rd r Creel*X 71 4 canine- c/IV
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Signature: _ _ Date: 97 //Cj
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Print Name: eraA-e e!
Refund Polity
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b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 , ; /y By °. . Rte to Bldg_\dmin: Date 2/ '9 j�/ By ;!
Refund Processed: Date 'v ff By . 4.4 Invoice Processed: Date // By
Permit Canceled: Date f3/2//y By Alr •arcel Tag Added: Date - By
Receipt# Date 7 Method Amount$
I:\Building\Forms\RegPermitAction_062614.doc