MLP2015-00008 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT \ I ( fl
i --- .'PIRequest for Permit Action �2/zy//5
, ,,,,,, , , 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 D Contractor VI City 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):
1E 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 #: ALP2015- OOX
Site Address or Parcel#: 9 615 SW Ff t ii r/i a
Project Name: 13cta-0(14, ( ?ac-h-H o{)
Subdivision Name: 11 � '' Lot#:
EXPLANATION: cc eOCh1 in erfn( — no 1 e,s suhm;+Fed
Signature: yobl 1 Agy Date: 1212216
Print Name: Ti m roa
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: _ Date/2_/2 y /s B
Refund Processed: Date .-✓j# By /Jj Invoice Processed: Date By
Permit Canceled: Date /Z/210.5 By ' Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_09'2314.doc