Permit Support Document (168) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 0 1 0
Ilig . Request for Permit Action VO, 4tft---
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I G A R D 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 ity Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL/VOID PERMIT APPLICATION.
D 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#: Et C i 6 -on 5q(0
Site Address or Parcel#: /Y/63 //s*' (9-.
Subdivision Name: //j4V /? {�/.�,}c 1 Zot /5— Lot#:
EXPLANATION: (-> mrce,d �-. ,.,1+ ryv ev-r we CI-C- ii, ...44 1
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Signature: .,.. � .c ,�'� Date: `7/o �/t1
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Print Name: re-ht..z-6...._, if- ,
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date '7 . G 6 By K, Route to Records: Date c�//y,/' By,h---
Refund Processed: Date By` Invoice Processed: Date f By
Permit Canceled: Date V' laf(,,,, B arcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_0923'14.doc