Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
ii _ ' Request for Permit Actin V 0 I0
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1 (;A I? 1) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.g/'' /42
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(V)one
REFUND OR Name: ` /14INVOICE TO: (Business or Individual) ?J
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
NCANCEL/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 #: 1)-)Q. 020 (Co— 0p00g
Site Address or Parcel #: 97 7 9 (,J 1-k-- ' Eit•)Cor O PD.
Subdivision Name: CSM Yb Lot #:
EXPLANATION: CiE..R--rE`tD „N1 f_2.1.o2. . (E, L LP PF4P HIT No7-
--PLQU l 2A-b A s J e L 0,2E' /Ts
Signature: ' tS.w�-�-U Date: I e:/�6
Print Name: �f 6�j, E A MSA /
Refund Policy
1. The city's Community Development Director,Building Official or City I?ngineer 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 VS postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to Sys Admin: Date 1'6tp 1 4, :t,JL r Route to Records: Date .25 /0 By Vii,/
Refund Processed: Date Nlp By ill Invoice Processed: Date By
Permit Canceled: Date .2/24//0 By 6 4•; Parcel Tag Added: Date By
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