Permit Support Document (165) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT I p.;>, ! 0
Request for Pern�t Action
T 1 G A R[) 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: '""
Check(✓)one ❑ Owner ❑ Applicant 0 Contractor ity Staff
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.
0 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#: `S t`"` 1 -ct)5 0
Site Address or Parcel#: l os` ) ---71i elt'
Subdivision Name:
Lot#: -
EXPLANATION: �.p .9p /], r� / p �p
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Signature: ill '
Print Name: AO
Date: /A/;37//4,
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 I,1 a -�
� By 63.1 Route to Records: Date / /, /7 By
Refund Processed: Date AS1 By Invoice Processed: Date
Permit Canceled: Date / By
� //� By Parcel Tag Added: Date By
I:\Building\Forms\RegPemvtAction_0)2314.doc