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Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 0 Request for Permit Action 1 1 , 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigtrd-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBu.ildingPermits @tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor Sr City Staff Check(1)one REFUND OR Name: �� INVOICE TO: (Business or Individual) �i 0-6-711&.4-0 4�� �l1 O Y ` IOC.) Mailing Address: ��3 �a-�cr-c��� City/State/Zip: c:::' 4e._ CL..QI�:.2�c� Ce, 9-703 Phone No.: '5P)-- 3q7 - 7 5 7 7 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): / CANCEL/VOID PERMIT APPLICATION. •__._REFU_ND PERMIT FEES (attach copy of original receipt and provide explanation below). ' ►�- INVOI R FEES DUE (attach case fee schedule and provide explanation below). VI RE /REPLACE CONTRACTOR ON PERMIT (do no e permit). Permit#: 5--c3,0 CSI Zo 2,0,10/S'G'OC 5s- Site Address or Parcel #: 59.1a 6u-2) I Project Name: c-LVI t J I Subdivision Name: ��, Tti 'Jt;-b.2 1 .&L Lot#: v� EXPLANATION: A. v& .J. 1 ij'2 , rao S--co t , -00 hat- Signature: ( Date: S Jo f l5 Print Name: 1T£PPv4_ 1)tll�1` ) tt 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 01.FlCL 151:. ONI.I Route to S s Admin: Date ;,IiLVQlIPr Route to Records: Date g©® B I Refund Processed: Date B u eM Invoice Processed: Date ' /S B Permit Canceled: Date - B 1 1 'arcel Ta:Added: Date B I:\Building\Forma\RegPermitAction_l 23 4.doc