ZCA2012-00001 City of Tigard • COMMUNITY DEVELOPMENT DEPAR711f?1-4-
Request for Permit Action
13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or goy
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: N/A
INVOICE T O: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
® 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 #: ZCA2012-00001
Site Address or Parcel#: SW Locust St and 13950 SW Alpine Crest Wy
Project Name: Paull Property/Wilmington Ln/Locust St annexation
Subdivision Name: N/A Lot#: N/A
EXPLANATION: The city was the applicant on this case. Application was never
complete. The request was re-submitted (see ZCA2013-00004& ZCA2013-00006).
Signature: NV44— &41-� Date: 7/6/15
Print Name: Cheryl Caines
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
• ' OFFICE USE •
Route to Sys Admin: Dat I By I Route to Records: I Date - /f B
Refund Processed: Date A/ B Invoice Processed: Date B
Permit Canceled: Date B Parcel Ta Added: Date B
1:\Building\Forms\RegPemmitAction_0 31 .doc