Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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1111 Request q est for Permit Action /� �s/
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TIC;,,R i 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or god `
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 (✓):
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#: idupAo/y O 3`�
Site Address or Parcel #: F& a 64) Vr. Vil2i,KG ,
Project Name: P- "t n;Jo o fvN
Subdivision Name: Lot #:
EXPLANATION: is `, r- 0 -✓C. a- _ _. 1� , /tet .r
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Si ature: /
�. _ il.44L-4 4' Date: `-/ /i /1
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
route to Sys Admin: Date (tr.( By I"l Route to Records: Date // /,f Al-- B- '
X alis n Processed: Date / � By ;, a Invoice Processed: Date By
1 Permit Canceled: Date // /S7/ By ': -el Tag Added: Date By
I:\Building\Forms\RegPermitAction_09_314d/oc