Permit Support Document (40) V 0
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action
T ;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@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractortry 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):
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#: 7)),fi `t -W '
Site Address or Parcel#: 15/ 7' ' � /'�.,. 41,
Project Name: /' W,-4/ / td--1--
Subdivision
c-I-Subdivision Name: / vSJs Lot#: 7
EXPLANATION: . J3 3 ' /lnl c' •',':)r /°y7
r
Signature: / ate:
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 g )-3),>s By R',71 Route to Records: Date 9 re B
Refund Processed: Date / By At Invoice Processed: Date By
Permit Canceled: Date 9/4"// By '/Q Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction 09t314.doe