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DCA2018-00001 d c n o '16 otx) o � © 0 0 0 VOID City of Tigard a COMMUNITY DEVELOPMENT DEPARTMENT G� / y „ye._ IN �x ` Request for Permit Action TIGARD 1 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 ITEM(S) CHECKED (1): X 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#: D'A-2-01 sg --0 ©1 Site Address or Parcel #: Project Name: Subdivision Name: Lot#: EXPLANATION: C ed . C '&.6. /9.d �f cf ®d '1- Signature: 'r`�%r' (Q � Itg Date: Print Name: ''/ niS L-tv4Or 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 • Not more than 800/s of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 By Route to Records: Date ,j= / /I-- B Refund Processed: Date /✓ .9- Byil Invoice Processed: Date By Permit Canceled: Date /,,F., By4ftfr Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_ 92314.doc