Permit Support Document ECEI VED
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT MAR 2 2020
_ Request for Permit Action SUILDINGDIVISION' D
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD VOID
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223 3/7/2 aCJ `_
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 2v-v5 \- -.. 5 I\
Mailing Address: r2 5 33
City/State/Zip: r5c"-'v p'CL r1J7 pos
Phone No.: S O — (, SAS-- ®9j 'L
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL/VOID PERMIT APPLICATION.
D REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
0 INVOICE FOR FEES DUE (attach case fee schedule and provide e1 _
Permit#: /V ' _j
Site Address or Parcel#: 7 rf 7 S LIB
Project Name: e'c C.1*1-34-1',rl.
Subdivision Name: Lot#: 2,2,2
EXPLANATION:
Signature: Date: /L/2 n
Print Name: rh.,D /}-pry •
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 Adttun: Date By Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date By Parcel Tag Added: Date By
I:\Building\Forms\RejPermitAction_120518.doc