Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1
7 .
= Request for Permit Actions /
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 0 i�C ty Staff
Check(✓)one
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.
El 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#: ., j j
Site Address or Parcel#: /(J') 2,j SzA3 ,f
Subdivision Name: '"—' Lot#:
RXPLANATIC N:
ri '/
Signature: Date: ,.�/, /-7
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date 07- i 7 By , Route to Records: Date3 q /7 By
Refund Processed: Date A/ By Invoice Processed: Date By
Permit Canceled: Date 31 //^7 By ,e9W Parcel Tag Added: Date By
I:\Building\Forms\RegPemutAction_0 23 4.doc