ZON2015-00001 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEl O 1 0
NI • Request for Permit on
Acti 3/ /s
r i 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 [(City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) N 14
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
VCANCEL/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 n of cancel permit).
Permit#: Z J O f' )/ 5- 0000.
Site Address or Parcel#: /31 2 S .J-(q l/ f i/c1
Project Name: i y f-f " .rra
Subdivision Name: Lot#:
EXPLANATION: * 2 a a I • — • t I •
5-ex, Gam -44 Z DAJ 2C) 'f- Co oDa f C 60---e_
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Signature: A/_,_ _ UP Date: 3/
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Print Name: . - )/ ;U q
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ONL'
Route to S s Admin: Date B Route to Records: Date _ B
Refund Processed: Date Ai 't By der. nvoice Processed: Date By
Permit Canceled: Date ,3/�,/S By ,/,., Parcel Tag Added: Date By
I:\Building\Forms\RegPeanitAction_O 2314.doc