Permit ErCity of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT\ 1
Request for Permit Action ,�4
T I G A R D 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits @tigard-or.gov
FROM: ❑ Owner ❑ Applicant Contractor tty 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):
0/NCEL/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 CON'IItACTOR ON PERMIT (do not cancel permit).
Permit#: /37 c O/S---Ocir)//
Site Address or Parcel#: ej,me(p s c.() /,Gl/4',Y C4 S r"Y
Project Name: 71" ,S rziaC
Subdivision Name: !`^ Lot#:
EXPLANATION: L C Pe v - ,
IA.// (C1 • .• !. .i i -(. +� r> L ._I �"•
Signature: / Date: _/1225
Print Name: c
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or 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 via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to S's Admin: Date / j7 B . Route to Records: Date /®9AMI : ;i ii
Refund Processed: Date A/ By gn Invoice Processed: Date By
Permit Canceled: Date //f/, By ► r arcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_(l92.14.doc