Permit 12/16/2014 03:57 5036849015 WESTERN PLUMBING INC PAGE 01/01
IP14
V DEPARTMENT
City of Tigard COMMUNITY DEVELOPMENT,� 12014 LI
Request Permit Action ��ryo; _
1 .4.;,,l,D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • ww 1 L s . .�.t ...
TO: CITY OF TIGARD V �/ „ri.
Building Division Services Supervisor f a /1 /
13125 SW Hall Blvd,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: In Owner ® Applicant ❑ Contractor ❑ City Staff
(check one
REFUND OR Name: Western Plumbing, Inc.
INVOICE TO: (Business or Individual)
Mailing Address: 9460 SW Tigard Street Suite 101
City/State/Zip: Tigard,OR 97223
Phone No.: 503-639-5296
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
® CANCEL/VOID) FERMI! 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 4: S '-2014-00129
Site Address or Parcel#: 13535 SW 72' 'Avenue#200
Project Name: Umqua Bank
-
Subdivision Name: Lot#: —
EXPLANATION: All 4 sinks on .ermit arc to be relocated. No sinks will be added.
1. . . • •
Signature: ,` 3 f( Date: 12/17/14
D ensen
Print Name:
Refund Policy
I. The Comnnunity Development Director or Building Official may authorize the refund of
a) any fee which was erroneously paid or collected.
b) not more than 8(1%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 13(1%of the building permit fee for issued permits prior to any inspection requests.
2 All rafiinda 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 S s Admin: Date ®z o am Rte to Bl._Adman, Date ,_���� B' . 67.411
Refund Processed: Date Air By_=AAI Invoice Processed: Date B
Permit Canceled: Date a ,' ,y 13y 1C'' Parcel Ta_Added: Date B
Receipt# Date Method Amount$
1:\Building\l otms\RegPermicActumw062614.doc