Permit City of Tigard • COMMUNITY DEVEE(1PNIENr DEP.\RT-.'IISN'r V
■ Request for Pernut Action
,
13125 S\\' [tall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • wuwv.tigard-or.gov/OG
TO: CITY OF TIGARD
Building Division
13125 S\\ I Tall Bh-d,Tigard, OR 97223
Phone 503-718-2439 Fax: 503-598-1960 TigardBuildiugPermits@tigaxd-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ❑ Cin- Staff
(.),(rk(✓)on(
REFUND OR Name:
INVOICE TO: (Rusin—"a lndicidul)
MailingAddress:
Cinv/State/'/,ip:
Phone No.:
PLEASE AKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCE],/VOID PF'RNi1' :APPLICATION.
❑ RFFL—ND PHRaA11T FIeF.S (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FFES DFE (attach case fee schedule and provide explanation below).
❑ RP.NION"1:/RI:PI.ACIi CONTRACTOR ON PFRAIH (do nor cancel permit).
Permit #: 003,2-?
= 0039
Sitc Address or Parcel #: l s�d �S� �'4 A baJ.4 ��.✓_
Subdivision NameTl1Yd✓o / lfylj- Lot #:
EXPLANATION:
4/ I 7fri a /�$%"� ^nt7�- /�Gcblilra(7 �U/ S=/off/ /Gi
Signature / Date
Print Name: �� f�
R,hind Policy
1. I l" eitc''s Communftc-Deeolopment I motor,Building()tficml ur Citc I:ngjn,,r mac authorize thu refund ot:
• .\nc fl( 1111('11 was anoncuuslg paid or cnllcct,dl
• Sot more than 80(" of rhe application or plan rccicw tac(ehcn nn application is(withdrawn or canceled hcforc!ev'Iew eftbrt
ha.1),m exPwndcd.
• Not more then(80°'x,otthe application or permit fee for issued permits prior to ane inspection request,.
\II refund,will be returned to the oripul pavtr in the toren of a chick ria I S postal ncn'icc.
3. Plea,, allocw 3-;u',,ks fur prneessing refund ,qu,,ts,
Route to Scs_\drain: Date Bc �. Route to Records: Date
Refwad Processed: Date 13\ Im-oice Processed: Date B1'
Permit Canceled: Date / / B Parcel fag Added: Date BN
I.Aliufld,ng',formsARoy Prmtit Aciin_u9B J.diic