Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT /y I
/7/;9Request for Permit Action
T 1 G A It[) 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • wwwrttgaracix,g
TO: CITY OF TIGARD SEQ
Building Division
13125 SW Hall Blvd.,Tigard,OR 972230,
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPFrmits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor goCity 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):
- CANCEL/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).
Permit#: F-Ps M 'j20 /(7
Site Address or Parcel#: 6::&S
Project Name: /7%-)
Subdivision Name: Lot#:
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Signature: Date:
Print Name: �� s(l1��CL✓G�
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ^'j 4, By Route to Records: Date ' �i3 /9 By
Refund Processed: Date "1/4/7 - By Invoice Processed: Date By
Permit Canceled: Date 7//3//9- By „ Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1'20518.doc