Permit Support Document (122) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT �/ 1
y 11��"
Request for Permit Action // 7/A
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 CFI City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 1, 1 (
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
[Rt 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#: ��h' p j (D — CC 'L 1
Site Address or Parcel#: 1140o c_z
Project Name: \I I Q.-1—LA
Subdivision Name: n Lot #:
EXPLANATION: C.i E�TE7l
j �j12o/JC0 PFS H I7-- 1 `'Pt_. .
s-- e9ot (.0-doy41b
Signature: a jg�Q Ci&vi-l.tL.kJ Date: 10/ l //4,
Print Name: -ID p,l g (� nf}1. .5K.I
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 i• 3/ /6 Route to Records: Date ///gr/ B //►
Refund Processed: Date 4//.9 By Invoice Processed: Date By
Permit Canceled: Date /``7/4, By T--, Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_0 23 4.doc