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~Mq <br />REFUND REQUEST <br />APPLICATION <br />Planning & Development <br />Building & Permit Services <br />99 W. 10t' Ave. <br />Eugene, OR 97401 <br />(541) 682-6806 Fax (541) 682-5283 Information <br />Date•P 2q a <br />Permit jb-CS,j11 Z - O 1 <br />Applicant Name Phone Number <br />Job Site Address <br />Mailing Address (if different) <br />Who paid the permit fee? ' Mailing Address <br />SDC fees <br />Please provide a detailed reason for refund request. <br />L LD 2,;Eos lcti] - w cry,-ft:~r 6gA fz6fr <br />Please submit this completed application to the Receptionist. You may also fax it to <br />(541) 682-6806, or mail to Inspection Support staff at the above address. If you have any <br />questions please call (541) 682-5283. <br />Staff Results and Comments: fy56. ~+e Za 6 7. pm dv' <br />Documentation to support request must be attached (i.e. copy of permit, receipts <br />151- 4alI - 0aa~- = -1 ao <br />535 -C,':3a5 -Lj a-L5o= so Q-2- <br />5,5(p - 935-5 - Ce t8 toy - q qy~,Wa - q;g <br />\\cesrv400\public\DMSIONPDD\BPS\PICFORMS\AIST%Support\fee refunds.doc <br />-IRUD <br />