Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT
DEPARTMENT
t ue V 0 I
Re t for Permit
s o e Action
Request 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(V)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.
❑ 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).f
Permit#: &VAC)/ 7—C-74).?-35
Site Address or Parcel#: i?316 I C8
Project Name: Wald f ,,Gp 1 i/"leai;l'ii pest
Subdivision Name: " Lot#:
EXPLANATION: / et-kel t ,AI c..vr v. Com,p' ,kJ'fr 4 ry
8.41 r'7 -.0(.43g i ive0;40D ye. Ale-to "4 .y'
/I/ M 1 c' C/hS ,, r.7 y .�
Signature: Date: q/i/i 7
Print Name: +e134fde_Ai• I7
4—,
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
rub Route to Sys Admin: Date •%1/ /7 By/3.77 Route to Records: Date • 6 /7 By
,rmA6 - efan&Processed: Date -7161/7 By Invoice Processed: Date By
Permit Canceled: Date /4, ? By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_0§231 .doc