Fillable Printable Permit Refund Request (F621-105-000)
Fillable Printable Permit Refund Request (F621-105-000)
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:
Electrical
Elevator
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:
$
Permit/Conveyance Number:
Request Payable To:
Address
City
State
Zip Code
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
Payment Date:
Check Number:
Transaction Number:
G.L. Codes:
Electrical Only: Number of Req.
Electrical Only: Number of Inspection
Credit Card
Debit Card
Cash
Check
CD Account
ACH
L&I Inspector/Employee Name:
Full Approved
Partial Approved
Request Denied
Refund Amount Approved: $
Additional Notes:
L&I Inspector/Employee Signature
Title
Date
Supervisor Signature
Title
Date
SCS Fiscal Tech Signature
Title
Date
F621-105-000 Permit Refund Request 02-2015
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