Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 D
lig _ Request for Permit Action 02/02614, ,,,a1
ii,,;A I: 11 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 cs. City Staff
Check(/)one
REFUND OR Name:
INVOICE TO: (Business or Individual) f A.
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#: N_,M o2p l Le-600 340
Site Address or Parcel #:
Subdivision Name: Lot #:
E PLANATION: -j, . 1 4 tAA, Li' , C0..,,-- / • , i
yv- � vet'lALi(VI - �.Q rL
Signature: I , t I ,
Print Name: t-)EAP»g Pt','N.ILki-a-1,-
Refund Policy
1. The city's Community Development Director,Building()fficial 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• Not more than 80°%of the application or plan review fee when an application is withdrawn or canceled before review effort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°'1i 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.
FOR OFFICE 1.-SE ONLY
Route to Sys Admin: Date 0-RA rte I , I' Route to Records: Date _ .2,5 4, By -
Refund Processed: Date pi By AA Invoice Processed: Date By
Permit Canceled: Date 627,P 0 B,j Parcel Tag Added: Date By
I:ABuilding\Forms\RcgPenmt.Action_ 9231 doc