Permit Support Document (34) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
9 Request for Permit Action
IN .
T 1 C;A RD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.ti ov
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TO: CITY OF TIGARD
Building Division Ptia g g 83d
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPerrnitsQ tl• ,11 telk„j31.-3
FROM: ❑ Owner [, Applicant ❑ Contractor ❑ City Staff
Check(V)one
REFUND OR Name: Vj l r",) I
INVOICE TO (Business or Individual) /1I f ZOt - �'(�,,,,.�bi i,, A�%,Mailing Address: t0() 6o,� CT� ®
City/State/Zip: C.,IGJs,uN. , O 1( ''17 -
Phone No.: '--63 - 2.01 -5-2,--e
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
KCANCEL/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#: Pt iii 2018-QUO W
Site Address or Parcel#: CO5- :..51,./ Ar Z S
Project Name:
Subdivision Name: Lot#:
EXPLANATION: 6,,%ortrr cA:ji Ao f- 1,,,c L ,--c0/4 5-e.L.,Z' bi_ L
Signature: /'}�, ��.- Date: 212_ 24 / ?
Print Name: 4,,."c.A l_--e—C--
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
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FOR OFFICE USE ONLY
Route to Sys Admin: Date 0Alp,r By ] Route to Records: Date .2/.42-2 /9 By - -.4-'/
Refund Processed: Date ,,4 13Invoice Processed: Date By
Permit Canceled: Date /L�/E 4
By 'U Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_0 314.doc
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TIGARD
City of Tigard
April 18, 2018
Mr Rooter Plumbing
PO Box 789
Gladstone, OR 97027
Re: Permit No. PLM2018-00048
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9755 SW Inez St.
Project Name: Frederick
Job No.: N/A
Refund Method: ® Check#228185 in the amount of$64.96.
❑ Credit card"return"receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account"deposit" receipt in the amount of$
Comment(s): Per applicant's request as job was cancelled. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
411.
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov