Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 D
is Request for Permit Action
III
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@tigaxd-or.gov
FROM: 0 Owner 13 Applicant EI Contractor ri City Staff
Check(V)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Boones Ferry Electric
Mailing Address: P.O. Box 628
City/State/Zip: Wilsonville OR 97070
Phone No.: 503.682.4936
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (/):
0 CANCEL/VOID PERMIT APPLICATION.
111 REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
Ill INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: ELC2019-00298
Site Address or Parcel #: 12646 SW Karen St# 31 Tigard OR
Project Name: Bellwood Terrace
Subdivision Name: Bellwood Terrace Lot#:
EXPLANATION: We have worked/permited in many units this permit was pulled
in error
Signature: ILK.Oill, „,_,........-------\
(.74, th ----7.....m<
Date: 11/8/19
Print Name: Keith Fleschner
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: Date verp,/, By.ff--745.4----.
Refund Processed: Date /1j/..9-- By-jf2-6/ Invoice Processed: Date By
Permit Canceled: Date ///2://‘/- By io- '. eel Tag Added: Date By
I:\Building\Forms\ReqPerrnitAction_126518.doc