VAR2015-00025 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1II I. 0
Request for Permit Action / 272 YAS TIGARD 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 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):
CANCEL/VOID PERMIT APPLICATION.
-PrEFetilE,PERMIT FEES (attach copy of original receipt and provide explanation below).
Tr ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: \% 2'f1 -6a&27.
Site Address or Parcel#: -3/s Su-1 /3 u diih< / 5
Project Name: ? ($eJ�-I(
Lot#:
EXPLANATION: Ef vTL-7Leb > Ve5 [1/ vOsfM (4'47)
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Signature: � Date: /Z -/O /S
Print Name: ??e<4;L:(
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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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: Date /4/2 v /S B„rpiy •►�”
Sreit4k-ftTfittProcessed: Date/2.-h.y//_.S B " Invoice Processed: Date By
Permit Canceled: Date/ 9/// B -. ! Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_09 314.d c