Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 1 D
Request for Permit Action ?�3/is ,
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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- /A
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
6 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 #: LO t�01 5 - ono 2 to
Site Address or Parcel#: 1 a.a-ts(p O�S r J Y R
Project Name: —t31.)-e_1 r 1 c_.----- t_N.)TAL-- cre1,2.6 1QS
Subdivision Name: Lot#:
PLANATION: ----1-Th LLA LA C -y If_.2 M Cr, £ LL;Q_ Ol 5--coo6
10 HOtot_y 0oLLICTtb
Signature: _ 0 P A l
Date: –74--1/S
Print Name: EP,1 c (Z 1--Det-A-te- i•[•--y
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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: B Route to Records: Date B t�i'>•
EM MEN �i- ���� .tom
Refund Processed: Dat- LAIN B ;a-a Invoice Processed: Date B
Permit Canceled: Date(FA LS By '�e Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_69 4.doc