Permit MCity of Tigard • COMMUNITY DEV EL(mNtENT DEP.vRT.NIEN'lV 1 D
Re uest for Permit Action
9 i iii
13125 S\V' Ball Blvd. - Tigard, Oregon 97223 • 503-718-2439 • www.rigard-o .eo
TO: CITY OF TIGARD
Building Division
13125 SVA-I lall Blvd.,Tigard, OR 97223
Phone 503-718-2439 Fax: 503-598-1960 TigardBuildin#Permits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor pa Cin' Staff
check(V)one
REFUND OR Name: I/�
INVOICE TO: ns;ncsr or IndkiJiuq N
Mailing_Address:
Cin,/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
C.\NCEI./\'OIl) PIiR
R1?FUND PER1\11T P1?J:S (attach cope of original receipt and provide explanation below).
❑ INVOICE. EOR FF'ES lll7E (attach case fee schedule and provide explanation below).
❑ RFNIOV'1:/REP].:ACE CONTR.AC'1'O1Z ON PFRAIFF (do not cancel permit).
Permit #: I 1 �' c9O ( I-V - C700 a-a
Site .Address or Parcel #: 15 3z )0-"g.j Y4)L)f--
7+ p2 �t73
Subdivision Name: nn Lot #:
P
EXPLANATION: �QqTh
£'b LOP-ox)G P-MI TII YPe
GLC 20/(Q - DD� f?.
Signature: Date
Print Name —L �p
Retinol IN dice
I, The cm"Communitc Development Director,Building()ffcial or Cin ICngineor mac authorize the refund of
• \na ft, which was crivncoush paid or collcctcd.
• \ot nose than 80""of the application or plan review tee when.u,application is c%irhdnmit or Ca11r011Ll brforc review ettbrt
11.11 bccn c1pundcd.
• Not more than So°b of duapplication or permit fco for issued permits prior to im inspection reyucas.
_. \II refund,gill be rammed to the original pacer in the torn,of a chock iia L'S postal serm L
3. Plcasc allow 3-4wcoks for proccssnig rchind rc4uosts.
Route to Sts admin: Route to Records: Date / / II,
Refund Processed: DateInvoice Processed: llate B\
Permit Canceled: I Date / / 13v Parcel Tag_Added: I Date IIv
V I$uldiniVhams\Roypcnnn\ctin,—I i9°314-doc