PFI2014-00082 City Of and T1 • COMMUNITY DEVELOPMENT DEPARTMENT i g
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Request Permit Action 1091- 19111
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tilzard-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 (✓):
X 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#: W-( 2Z�)l y —QD09Z
Site Address or Parcel#:
Project Name:
Subdivision Name: Lot #:
EXPLANATION: Pffrmlf- in* YV�AVIWd )01 \N n�- MA 12 n\(AI /
D1170riY�/1 • �
Signature: Date: IDI 11114
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Print Name: iA
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b) not more than 8W,o of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 811"o of the land use application fee for issued permits.
d) not more than 80('/o of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than&loo 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 Pae mens was received. Please allow 24 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date ii\ I Ric to min: Date B
Refund Processed: Date /✓f-f By Invoice Processed: Date By
Permit Canceled: Date Zv 2�LIZ B Parcel Tag Added: Date B
Receipt# Date :Method Amount$
l:\Building\Forms\RegPcmmitAetion.doc Rev 05/25/2012
To:Attn: Brandon Page 2 of 3 2014-09-25 16:46:16(GMT) 15039721866 From: Matthew Lowrance
RECEIVED
V 0 1 Q SEP 2 5 2014
,�. City of Tigard` fa�y�iy , CITY OF TIWD
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Descriptiop of work: RP r.,C- ”
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Estimated value of work(%%ithin the public tight-of;wavS
Is work related to a I1lItI3-l3S1✓IlECISTOti? RFs ❑ r0 71
If so,please speciA,(NI MP,SDR,SUB,etc,).case##:
Is the worl,related to a BUILDING PERMIT? -.'I S NO
If so,please specify (BUILDING PERMM case#:...... .. . ------------- — -__..... ................... _
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To: Attn: Brandon Page 3 of 3 2014-09-25 16:46:16(GMT) 15039721866 From: Matthew Lowrance
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