Permit Support Document (20) v r-)
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTf/Aci/7 44?
Request for Permit Action
FIG A R l) 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@tiga r.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City 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):
ANGEL/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).
Permit#: car 7.,..,c�1
Site Address or Parcel#: 10 eL ✓ti
Project Name:
Subdivision Name: Lot#:
EXPLANATION: C• ,. -4't-' f .L! t✓n,r Rue
:)e- " Arn. ►�1�.,,d }r vhn,I *fi I4' - )i?--c k>t3
Signature: Date: / /;
Print Name: Date: //////,/' 7
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ESE ONLY
Route to Sys Admin: Date j/ / /7 By r Route to Records: Date
Refund Processed: Date /Jig— By .�,— /7 By ` Pew"Invoice Processed: Date By
Permit Canceled: Date///,//7 By ',: Parcel Tag Added: Date
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