Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0
III 4
Request for Permit Action /- 1/4 7
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(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE AKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL/VOID PERMIT APPLICATION.
0 REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
0 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: Ai`'1Vt)/7—Ck)7 2J
Site Address or Parcel#: .2) �� ii, /9,.
Subdivision Name: Lot#: lel
EXPLANATION:CKre.tet () Mif 4v e44-6v. -7A,_3. /.�02,,,i:74 ,
4 ani r 7.c- ice'► , /t'C fry', ice- /1',;2G i 7''t.Y fi3`VI
Signature: -,— v _ -- Date: /023/),
Print Name: . . /
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 e. , Route to Records: Date- .'2 /7 :1� it
Refund Processed: Date N7 By if Invoice Processed: Date By
Permit Canceled: Date,2/p.Ji'7 By Jr' Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_092`344.doc