Permit Support Document (44) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V I r-t
RequestIII .j
for Permit Action 4/�- 4 ---
TI G A R 17 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 ❑ Contractority 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):
LANCE OID PERMIT APPLICATION.
ND 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#: 5-6)/U//F (IOC
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Site Address or Parcel#: /75a) Sc:) '4i r 7S c 4, `_
Project Name: L6/ 's ` c' — , �
Subdivision Name: '�` Lot#:
EXPLANATION: ern 74i c:A' L �l
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i.hi G Cilet-Sis ap- 0 &._74 0z4 `—c'in/.
Signature: /`''.". _ - Date: IS/if
Print Name: /aj .aC(fw ic;.. ,
Refund Policy �f `
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 it 3/4 By . `. Route to Records: Date 9 A /�- BATI"
Refund Processed: Date N,*-- By. 1' Invoice Processed: Date By
Permit Canceled: Date L/ 4,//.p B ,/t Parcel Tag Added: Date By
I:\Building\Forms\RegPemutAction_ 92314.doc