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PFI2017-00049 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTV 0 1 D = ~ Request for Permit Action y//2// 7 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tiigard-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: INVOICE TO: (Business or Individual) C-71 S h Mailing Address: City/State/Zip: Phone No.: L i MD CTION FOR THE ITEM(S) CHECKED (✓): OID PERMIT APPLICATION. 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#: P L Z� " Q 0© 'IjC1 Site Address or Parcel#: Subdivision Name: Lot #: EXPLANATION: rec4d P f ?,�) ) () 0 U1 t &oVie -L ` j" i S (r L . C k p c9.1.y- is S2 d x �- T IC 1 -7 O OU'4!21 Signature: C-1 Date: I Z I Print Name: Q 1) ✓1 V) -7 i s Refund Poli 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. • ' OFFICE USE ONLY Route to Sys Admin: Date By Route to Records: Date y i7 7 Refund Processed: Date /1/ By Invoice Processed: Date By Permit Canceled: Date Y117117 I B Parcel Ta Added: Date Btu I:\Building\Fomu\RegPemvtAction_0 31 .doc