Permit Support Document (2) ..
City of Tigard •• COMMUNITY DEVELOPMENT DEPARTMEI ,/ 0 I Li
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Ifi I Request for Permit Action /c/3/i9 4 ",._.
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.ligard-or.gov
TO: CITY OF TIGARD w�
Building Division Y '%..;''
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPerms@tigard-or.gov
FROM: p Owner ❑ Applicant ❑ Contractor a7City Staff
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#: 2z.z.A at c? — S c^
Site Address or Parcel#: 11.16, 5Cv c:::?'7 7
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Project Name: T/„, -�i vy v atii- Ca/
Subdivision Name: Lot#:
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Signature: 1 Date: Yi2 i//
Print Name: //-23-74 ._ kk9Vth/C.14- .7 /
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 g ,z( f 1 By ;.71.n. Route to Records: Date GO 3 /9 By 41./
Refund Processed: Date iv/ �By ii' Invoice Processed: Date By
Permit Canceled: Date/6/1 y By trarcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_.120 18.doc