Permit Support Document (63) v n 1 D
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 3/209 <567---
Re uest for P r '
q emit Action
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T 1(;A R C) 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 0 i-Cty Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address: ., '
City/State/Zip>..
Phone NV
PLEASE--TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
Q"CANCEL/VOID PERMIT APPLICATION.
0 REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: 5!.-} r j'- 0OO 5
Site Address or Parcel#: /3645— ;5.J -el �-Y'
Project Name: C, ei-i--- 77 41 >
Subdivision Name: Lot#:
EXPLANATION: .14-2c4.4,4,I've� - i AA;7 l�e.0 C GT/1/2e iv '1.r'
/4/el,(e.tr71-[.W e ,-1 !Jhr" 4 yt ,ei Gtz 2 C iE") ' 7 .--4- AP-i 2794.
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Signature: ` �..,e Pate: d`�dcl
Print Name: 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date ; i 1 By 3 72'; Route to Records: Date /Z�/j l By
Refund Processed: Date r By „ Invoice Processed: Date By
Permit Canceled: Date F3/1;;//5 By •f''' `" Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_i2051 S.doc