ADJ2018-00002 City of Tigard • COMMUNITY DEVF.LOPMEN'1' DEPARTMENT
Request for Permit Action
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(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓):
LF1
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).
Permit#: L LA Lo Ig—00o o i
Site Address or Parcel #: 11- "ZO S�i 72— Ave. Tr:&), Q C<,
Project Name: :J2�l- JA\tt, Ag!,2-6",4
Subdivision Name: Lot#: —
EXPLANATION: fl&s(
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Signature: 14wmDate:
Print Name: S ahT,G tu aIX
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 • ONLY
Route to Sys Admin: Date By Route to Records: Date V1 / B
�& Processed: Date / /,f-' By Invoice Processed: Date B
Permit Canceled: Date / B Parcel Tag Added: Date B
I:\Building\l�orms\RegPermitAction_0923 4.doc