Permit City COMMUNITY DEVELOPMENT D � 14;z,„
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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(V)one
REFUND OR Name:
INVOICE TO: (Business or Individual) T rJ 6 0 E S [AD
Mailing Address: a30 (o° py,, LLD o C�� � ( u i T� IDo
City/State/Zip: L - OSLA.) � p2 ci7O35"
Phone No.: 5O - 3(n -
PLEASE
c n -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).
ja INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
n REMOVE/REPLACE CONTRACTOR ON PERMIT (do not can pmrit) - .-.•...
Permit #: t 55- G7cb Coo tt.). 2&o f 5-00c
Site Address or Parcel #: [50%Co r14.-\/ £vJin,ID
—rico t 02_ q-7,9,14 n
Subdivision Name: t_t-Tt 1 tit f w I`1�l�o ti(S Lot #: 7
EXPLANATION: 7T C7 l § )--t 51-a-v I Co- exp/l
�w(Z 2-c)l L - 00o 9'3
Signature: CDate: Zia4/ I
Print Name: - €j p,,4
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 , 9.3 r(ploty 1 Route to Records: Dat /L B NSF
Refund Processed: Date /1 ¢ r'>' 1< Invoice Processed: Date / f By
Permit Canceled: Date .2 /k By + Parcel Tag Added: Date By
I:ABuilding\Forms\RegPermit.yction_0 2314. oc