Permit Support Document (32) City of Tigard • COMMUNITY DEVELOPMENT DEP ARTME TNo , 0 goak
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(✓)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):
MCANCEL/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).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: �L (�,d0/ ' y Z
Site Address or Parcel#: ,4J7GecP'psf
Project Name:
Subdivision Name: — // Lot#:
EXPLANATION: ,27-1- 5 L1 r.C.C./o+° �'Lct!I C_ l%„-,, Gr ��/rh liG1 t--vcolci�
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Signature: //` ,' Date: �-
Print Name: J (t r_ OIL
Refund-Po'Gcy
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
•
0
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 ci B ,�7� T�'��
/ � Route to Records: Date yJ�A•
Refund Processed: Date/V Invoice Processed: Date By
Permit Canceled: Date /Wit- By 1,6--r arcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_0 2314. oc