Permit Support Document (13) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEN T 0
1
Request for Permit Action 402A7
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(✓)one
REFUND OR Name: N
INVOICE TO: (Business or Individual) / ►'T
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
E CANCEL/ OID PERMIT APPLICATION.
• REF ERMIT 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#: l&L-P O9 l 1 — 000 g 3
Site Address or Parcel#: I 9--°180 i{- i4 LL LK)
'rrG,--202 (47 aac
Subdivision Name: (� Lot#:
EXPLANATION: C €q-T€-� l�P�tJ Ce Y .sji i-r— tat, . 6_6.6.-
Ft'Tr c9-c.) — potp,
.6.-Ft'TTc9-c.) t`j — Doty,
Signature: Date: 4/4(i 7
Print Name: Q.koto t QSVNl
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 5' Ce /7 B Route to Records: Date V /7 /7 B. ..:;
Refund Processed: Date N/4. By Invoice Processed: Date By
Permit Canceled: Date y/j7/j7 B Parcel Tag Added: Date By
I:\Building\Forms\RegPem itAction_o 231 .doc