Permit Support Document (19) 0 City ofDEPARTMENT Tigard • COMMUNITY DEVELOPMENT V 1 0
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T I G A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD ii,4 ..' L: ,�,
Building Division ,,
13125 SW Hall Blvd.,Tigard,OR 97223 P,,
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPertnits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor S. 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 (1):
g CANCEL/VOID PERMIT APPLICATION.
�' RE44H-PERMIT FEES (attach copy of original receipt and provide explanation below).
111 INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: !.c/.V / 7 a&a I L/
Site Address or Parcel#: l-/ 3 3/ 5 (.) . g SGi1UCd "
Project Name: SLc Ptl�tG�/,6D f",
Subdivision Name: --- Lot#: —
EXPLANATION: Gn Y4-60c-d G, GS1i G° ti/h -0 ..j I icel G ,,,...-
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Signature: "` / i- Date: ; -702[// '
Print Name: S�,c le'z 1J(1l4&Gt. --
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 (/ f.( /1 By "i Route to Records: Date 6 , 42 '-••hid'—�p
/ rocessed: Date „pp:4 p`I B ..:10, Invoice Processed: Date By
Permit Canceled: Date ,f/ .
/, 7 By ' .:'- Parcel Tag Added: Date By
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