Permit Support Document (15) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
: . Request s t forV 0 1 0
q Permit Action
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 ity 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):
EP 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).
0 REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: -54t1,2 2.6.,% 2 — Z20...9/�
Site Address or Parcel#: /0472.5-0 _5-et,) c, c `-�/e?ic',,2_�.,- . 7,5
Project Name: $- /°G-c J-AI c
Subdivision Name: Lot#:
EXPLANATION: ( z�:4-~7 / t...'---722/2t,-72._, ,1/G) G G( //1.eg0 7e
Signature: 'L: Date: 7V/07
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
Route to Sys Admin: Date/Oe1 7 By t.•-, •oute to Records: Dated /p /7 B ,rt -, -
Refund Processed: Date f � 0 By Invoice Processed: Date By
Permit Canceled: Date /e tt+/f7 By ;'I -Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_092 14.doc