Permit €1t i If 7
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT0-61,:•'''. .
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Request for Permit ActII ion �Eoz _
T I G A R C) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.g�v� Ally,,
TO: CITY OF TIGARD
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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 ►moi City Staff
Check(✓)one
REFUND OR Name: V 0 I
(Business or Individual) F
INVOICE TO: I k ?/741/(.0 �-_,
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANC - OID PERMIT APPLICATION.
_ 4UND 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)- (_,L0 020 I to- OC 5 /
Site Address or Parcel#: (0'500 &z 1+--t Py -S A-0 e_ Pe-
-OA 6i-i-Le - £xTt.eaoe5
Subdivision Name: Lot#:
EXPLANATION: ,A--t--,i> (_oe_on)lo Pte_H,1 Types 1 g Flic,1,0t4,-co 7
Signature: (--- CeCk-r&_AL_IL4. Date: i-6//,
Print Name: -1-05g L4 ADO---t S(tom
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
Route to Sys Admin: Date its Ite '•y l" Route to Records: Date ' /(o /6, By /'rir
Refund Processed: Dat' By AI Invoice Processed: Date By
Permit Canceled: Date nvt , By ''- ' tel Tag Added: Date By
I:\Building\Forms\RegPermitAction_ 9231 .doc