Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT RECEIVED
1111 AUG 6 2019
2 Request for Permit Action CITY OF TIGARD
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard �ILDING DIVISION
TO: CITY OF TIGARDV 0 I ,
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223 J/7Af
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner n✓ Applicant ❑ Contractor ❑ City Staff
Check(/)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Riverside Homes, LLC
Mailing Address: 17933 NW Evergreen Place
City/State/Zip: Beaverton, OR 97006
Phone No.: 503-645-0986
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (3():
CANC /VOID PERMIT APPLICATION.
'i FUND PERMIT FEES (attach copy of original receipt and provide explanation below).
J 14jpINVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: MST2019-00097/ SWR2019-00080
Site Address or Parcel #: 7620 SW Hansen Ln
Project Name:
Subdivision Name: Elderberry Ridge Lot#: 016
EXPLANATION: Due to the easments on this lot please void this permit application
and all documents associated with the application.
,,- /
Signature: Lek l ��- Date: 08/06/2019
Print Name: Nikki Pruett
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: Date '7// B
Refund Processed: Date n//iI By Invoice Processed: Date By
Permit Canceled: Date 2//9 By _4.1' 'arcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_7 05I8.doc