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200 S. Anaheim Blvd., Suite 145 Anaheim, California 92805 (714)765-5153 Phone (714)765-4607 Fax www.anaheim.net/building AUG I 2019 B700 CITY OF ANAHEIM PLANNING DEPARTMENT BUILDING DIVISION REFUND REQUEST PROCESSING FEE $53.00 Provide all information below and mail to: Building Division at 200 S. Anaheim Boulevard, Suite 145 Anaheim, CA 92805 or fax this form to (714) 765-4607. Last Name First Name Company Name Mailing Address (Street) City/State/Zip (Area Code) Phone Number E-mail REFUND INFORMATION Job Location: Amount claimed Date Fee Paid: Receipt #/Permit #/Reference State Reason for Requesting a Refund – (Details): I HEREBY CERTIFY THAT THE ABOVE STATEMENT IS TRUE. Signature Title of Claimant Date Department Action: ( ) Denied ( ) Approved Name Date Comments: