Inspections (10) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT , 0
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III Request for Permit Action /.2././../-./4.,
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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 gi City Staff
Check(✓)one
REFUND OR Name: '
INVOICE TO: (Business or Individual) t.,,,, l'f
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
H.
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#: c�U Q, 0'2,01 (0-cc 392,
Site Address or Parcel#: 15? 3 O owl w t-£au.al ►9 Pt, uo / 4t. /5O
Project Name: ( /2y -7)2 (,)/ )JC0
Subdivision Name: Lot#:
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Signature:
C1)§-:). C /Linn -l'�! Date: ////G/IPPrint Name: / y,p,g f£ i iat l 6 k°(
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 /1 i4 i(p B Route to Records: Date /.//. /c:., By E/i•'
Refund Processed: Date /ii& By Invoice Processed: Date By
Permit Canceled: Date f �,2//(a By ._ Parcel Tag Added: Date By
I:\Building\Forms\RegPennitAction_0 2314doc