Permit Support Document (12) VOID
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ?/?//
I : Request for Permit Action
lit;,\it n 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
El Contractor Ity Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (susinessorIndividual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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#: /t'—Do i7/
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Site Address or Parcel#: aA) (orey2A,1b,.,-�y Jed
Project Name: g5P J
Subdivision Name: ` Lot#:
EXPLANATION: L -c t /1.e—Ar eC t�.l 114
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Signature: Date: "7//�,S�$'
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date B Route to Records: Date 4 2 //" By
Refund Processed: Date .t//,Q- By,4141 Invoice Processed: Date By
Permit Canceled: Date /7214- B Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_0923Y4.doc