Permit Support Document (164) VOID
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT /2`/o//5 4;44
■ n Request for Permit Action
o
1 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) /::2,//1 41.,jG/4/ .41 '
Mailing Address: /O 9 f /3 .S�
City/State/Zip: !/A,1l6,,vt� w/4– 9g--- 0,0G
Phone No.: ."�� 65's T7)
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
Ea---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).
Pertnit#: Si /,E'.R0/S---DO/a?d '
Site Address or Parcel #: / _,'"—dy's L3 1:24n
Project Name: jgpr 6P/&// /i,t,J.
Subdivision Name: 4/tem., C / //,,//i/j7, Lot#: 7
EXPLANATION: /� 'W �oor "4,"
Signature: —�%t -- Date: --,—/�/�—
Print Name: hr.d. /j4
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date (( if i‘ By Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By _
Permit Canceled: Date By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_092314.doc