Permit Support Document City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT/ 0 1III 3 0
Request for Permit Action /0r3`,1, xpiyir
TI G A R D 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 EI_•E-ity T ff
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.
❑ 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#: r Lam;l'( —oo, sG f
Site Address or Parcel#:
Project Name: �,,,L;7' tex)'c'` `-
Subdivision Name: Lot#:
EXPLANATION: 6 / ,
�vfpr-44.-Nr-..;717 /9. --4'rt-f ate-
Signature: Date: `d/5/f/
Print Name: j���.✓ � /may-
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• Not more than 800/s of the application or plan review fee when an application is withdrawn or canceled before review effort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 id 3 By Route to Records: Date,,d/3//9 By i'
111
Refund Processed: Date ^///f- By ir Invoice Processed: Date By
Permit Canceled: Date(O/3`/9 By >¶'• 'arcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1 05 doc