SGN2016-00071 I
Cityof Tigard • COMMUNITY DEVELOPMENT DEPARTMENT' 0
q//'(-•;1/6 049,19
1111 :. Request for Permit Action
on
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 g City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) -e C.l 1.1 0 l— T q i CA. 1\11 it/LC— L ve C
Mailing Address: `l
City/State/Zip:
Phone No.: 1 I — 2 cc 13
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
jEt 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 CON TRACTOR ON PERMIT (do not cancel permit).
Permit#: SG N 2_01 (.0 — 00011
Site Address or Parcel#:
Subdivision Name: Lot#:
EXPLANATION: V 0 1 C r eirrn; r , M df.cL-' I
Signature: Art l Date: 7 Z-7 1 1 v
Print Name: (V\ p n i c„, (3 i\o„cf2
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 p//6 /4, B
Refund Processed: Date A//4L By ,S Invoice Processed: _ Date By
Permit Canceled: Date 9//�//b By ,'- Parcel Tag Added: Date By
I:\Building\Forms\RegPemvtAction_O 2314.doc