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Innovative - Responsive - Professional
Permit Cancellation
& Refund Request
Building Services
Submit this completed form in person at City Hall or by email to
Date of Request:
Which are you requesting? Choose one:
Cancellation of a permit along with a refund calculated in accordance with KMC 21.74.025 Table 1.
Monetary refund only, without any status change to the permit (for example, overpayment of fees).
Specify the relevant site address:
Specify the relevant permit number:
(Examples: BSF16-02134, MNR15-54312)
Explain the circumstances or details of why this request is being made:
Provide information about the person making this request.
Phone Number:
Email Address:
Attach any documents that may be helpful in processing this request, such as a receipt or invoice.
Refunds may take up to 4 weeks to process.
Refunds are subject to the Kirkland Municipal Code (KMC) 21.74.025.
The recipient of the refund will automatically be the same person or company that originally paid
the invoice. The recipient cannot be changed.
For Office Use Only:
Invoice #
Receipt #