Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit 4./7-2/d- ,‘ -.
T I(;A l;D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-dr.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 isi City Staff
Check(1)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):
MCANCEL/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#: Ll`Z- 0 C X d O 470 7
Site Address or Parcel#: _(ey c $4 /7"''t i
Project Name: VUu 4e C
Subdivision Name: Lot#:
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Signature: /5,1(.4.04:406: Date: /i Pi r
Print Name: v �,�,ft ._ atirt kwa.ki
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 G( �/, By 4.7 Route to Records: Date(, 2y. /1- By-iiir
Refund Processed: Date,4/ B Invoice Processed: Date By
Permit Canceled: Date 2;/'/ B Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_O9./314.doc