Permit Support Document (6) V 0 I
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action
TIGARD 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(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.
D 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#: •c, (, ' C1.s
Site Address or Parcel#: \ G
Project Name:
Subdivision Name: i Lot#:
EXPLANATION: C2d ?x�t? �t� k�i 1 0c cc T
(`RST':)vACt- C.,
Signature: Date: U \Q \Gt
Print Name: ' •S
)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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 t4 Ct I t Ct By j-- Route to Records: Date 62 s t 1�/
Refund Processed: Date Nit By ' Invoice Processed: Date By
Permit Canceled: Date (p f o J i ' By t' Parcel Tag Added: Date By
I:\Building\Formo\RogPor aitActio!_120518.doc