PFI2017-00269 City of Tigard • COMMUNITY DF,VELOPMF,NT DEPARTMEI A 0
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Request for Permit Action
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 E] Applicant E] Contractor City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) k6u ����,� C N1 d,•�. i7 fle(zJsar���
Mailing Address: PO hf-
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANE OID PERMIT APPLICATION.
ND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: MW-04-6q
Site Address or Parcel#: SO ILJ E '� h l 5�� Qjt, 011
Project Name: �� ��
Subdivision Name: 1 Lot#:
EXPLANATION: Oa4Iltkk of
Signature: Gp Date:
Print Name: 'J4
Refund Policy.
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund o£
• 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date BRoute to Records: Date B
Refund Processed: Date BInvoice Processed: Date B
Permit Canceled: Date /2 BT Parcel Tag Added: Date B
I:\Building\Forms\RegPermitAction_09 314. oc