Permit Refund Request (F621-105-000)
Department of Labor and Industries
Mail to L&I office where you got the permit or to
the inspecting office.
Refunds must be requested by permit purchaser.
Approved refunds will be mailed in 2 – 3 weeks.
Permit Refund Request
A processing fee is charged for all refunds. Please print clearly.
Type of permit:
Factory Assembled Structure
Credit my CD account: Yes No (Note: Credit/debit card payments can’t be refunded to a CD account.)
Contractor’s License Number:
Date of Request:
Amount of Refund Requested:
Request Payable To:
Reason for Refund:
Has the work started? Yes No
If yes, please describe how much work has been done.
Print Name of Applicant
Signature of Applicant
This section will be completed by L&I
Electrical Only: Number of Req.
Electrical Only: Number of Inspection
L&I Inspector/Employee Name:
Refund Amount Approved: $
L&I Inspector/Employee Signature
SCS Fiscal Tech Signature
F621-105-000 Permit Refund Request 02-2015