PFI2021-00150 City of`Tigard • COMMUNITY DEVELOPMENT DEPARTMENT �' (p0/
Request for Permit Action
13125 SW Hall Blvd. • Tigard,Oregon 97223 • 503-718-2439 • �t"g�;`=<<nl :,t..�„__
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: �4ner ❑ Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name: '
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip: ( a v ii
Lf� i
Phone No.:
PLEA � TAKE ACTION FOR THE ITEM(S)CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
REFUND PER IIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule`and provide explanation below).
Permit#: _ / ta�/ -Z of -2-/ " (1 a/ -5�d j
Site Address or Parcel#: a a s 5 j lI' 'G Yl C r -6 t``1 02 %72,4:y
Project Name:
Subdivision Name: Lot#: J
EXPLANATION: Wiz 6&4- L{nA-E wWit✓ A4.r ate (sUU CI1 t�(�t�l�� C f 1;P_GSL
y
Signature: % 64/H/ Date:
Print Name:
Refund Police
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan recvew fee when an application is withdrawn or canceled before reviev.,effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
Route to Sys Admin: I Date By Route to Records: Date Tic
Refund Processed: Date By 4Invoice Processed: Date 13e
Permit Canceled: Date 4Z k12:,,dBy ,07d Parcel Tag Added: Dare By
l:\fluildirtg\Forms\RegPerm3tAcdocL]�ktt.
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City of d of Tigard Pr•I#: 202 -00150
ENGINEERING; DFPAWI'MENT
abPublic Facilities Improvement (PFI) Permit
PROJECT INFORMATION
�j TYPE OF WORK
Pro)ectname: 1 ,107 jd/tvpn, C.-'r Z"t?CWAit< fe-a Itz- —
L E t F ruxhisc['nlity 1C+ork
Brief description of project. rt�jk L.4- C�Y yl dtulu•IK I&-- 64 n< bt AN,l"GE, qtr unhn
TYPE 2 RCS'Sukwalk/Dti�cw ry/Scwr
T ---- — %X',A performed ka the purp..u.of
salewaik instalhnon nt repair
• D"Vmay approach installanm and spar
SITE INFORMATION / Sanitary sever lateral installawn and
location (address if available): �i' 7 �r i'� l✓1 -/ l f!4L mwn imt up
L TYPE YPE 3-Full Scaic Development Wor4
C9{9q 1 ��,/.} performed%ith land use 2M(wal whicii
J mcludes am::of the followiw.
• Sulxiivmvpns or Partitions
APPLICANT INFO/ RMATIO yt ! • sircetwuieruttg
Name: l� I N 1[f ��.Y i/F7 J�L'`j.�/"/�1 l7 • 5funlinc insulleutm for un url ower,
�[� j storm sewer, Tigard uatrr, .and 'Tigard
fl �t J Aym t/r Water tIcn Ice"CA
Mailing address: �j
�I 7nhn A< n_
Cit)'/State: d.L U1`— GL' TYPE4-Small<:CI)
1p:
0 TYPE 5-T4*Tningir
Phone: II''
Ismail: K� 'M A4-46 f yy'rl[J.Lidphone: NOTE: Type 1 and 2 applications may 1x
Contact name: C' t^'✓t U J•' �.4`yit emailal to _ t�triy,ij.. ,�,.�,1 5,�,•
Phone: Finail: 4fci eO-gm'44SaIt'ih"
CONTRACTOR INFORM/CATION ❑ Same as applicant
Name: �� GW lzS3 9,epUQell <1 CCB Number: Z'C
Mailing address:�.D. �Q � ��ly 5 City/State: Y+ I GX�IIft 114, D A "Lip:—7 1) --Z o
Phone: z�j 12 — 7 21 — V Email:
ENGINEER INFORMATION
Name:
Mailing address: City/State: lip:_.
Phone: Email:
ADDITIONAL INFORMATION
� rt
Estimated value of work is required(if over 55,1)00):5 (within the public right-of-way)
Is work related to a LAND USE DECISION- ❑l'es o (;ase number:
Ciryof Tigard • 13125 SWI fall Blvd. • Tigard,()regret 97223 • www.ugard or.guv 5t13-7182421 • Page 1 of 4
_ YJ��yZ{ tti�J2JL .� �BY.�' CU✓;wz�"t- ra/.��.cc�xr, (
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DEVELOPMENT ENGINEERING FEES
Public Facility Improvement(PPI)Permit:
INITIAL PF[PERMIT PEE
Part I: Required submittal fee is!(1/0 of the Net PFI Permit Pea See below for calculations-Minimum of$3W.
NET PFI PERMIT FEE
Part 2: All non-water system improvements engineer's estimate X 7%(less the initial PFl Pcmtit},cc).
WATER LINE CONSTRUCTION FEE
Part 3: All Public water system improvements enginectle estimateX 12°o,
Does applicant have aright-of-ray licettvef ❑1'cs ❑yi: TYPE I AND TYPE 2-Most include a sketch
(; showing:
Helen the wireless facilities standards,is the proposal
considered?(check all that apply): ❑Small cell C Macro El Dimensions
❑ Street Name
flow man31 instat'sites are PtoPosed as part of this permit ❑ Site Address
applicntiom?
-- TYPE 3-Must Provide 4 sets of plans (sized 24 x 36
The ProPo d equipment is Irxatcd on which of the following. or 22 x M) and an electronic version of all submittal
Public Right-of-Wax ❑Private Propertyg tra rr's- The plans must that include:
❑ Cover—Site,Vicinity,Abbreviation,Ixgtnd
If equipment is to be located on private property,describe the
❑ Genera'Notes(City,lC atcv,Seutr,etc.)
type&use: El Street(Plan,Profile`;
C Rater,Storni and Sanitan (Plan Pn)fdte
Cl 11'ater Quala Facilities
❑ Grading
❑ Landscaping/Crtc Pian
❑ Composite t1rility Plan(Electrical,Phone,Gas, Storni.
S>urirart•,pater,Signals,Street Lights,rtc.)
❑ Details
❑ Traffic Sight Distance
❑ Signing and Striping
❑ Street Light Plan and Photometric
❑ Engineers seal/signature
❑ Sheet label(project land use:name,revision and plan
hag block,dates and sheet numbers.)
❑ I npnecr's Construction Estimate
Additional Submittals
(Per land use eoncfidons,if applicable)
❑ Traffic Report
❑ Storm water Drainage calculations
❑ Georeclinical Report
❑ Preliminary Access"m f&ght Distance)
❑ Proposed Plat
❑ Pathway Design
❑ 1k"ater Provider Approval
City Of Tigard 13125 SC Hall Blvd. 11gtrd,()regon .:,-.•. ._ _
9722: w•ww ' -or. av 503-7
6t 18-2421 Page-[0j'4
r
APPLICANTS
NOTE: Person specified as Applicant"shall be designated"Permittee"and shall provide financial assurance G,r
uarrk,if required by the cin pursuant to TMC' 15.(4.140.
• %ith the¢cq tion of a utdity upetatrcy;Pursuant ry a solid f=ctvx or license wuh the(_in,of'I'*wxL when the nssmer and the applicant
arc different paiph-the applicant must be the purchaser of record of a IL,cc in possession with written autlo>nzaticm from the owner
or an a ra of the tamer. The owner trust sign this application in the space provided or submit a wnnen authorization with this
apphcavon Pnnehocd of Licenced Gdlirics are not ttquired w obtain the aunt's signature on the apphcau„n.
I,the applicant,certify that:
• To the best of my knowledge,all the informatitxi protiided within this application package is complete and
accurate.
• The above request does not violate ani recorded deed restrictions that may be attached to or imposed upon the
subject property.
• If the application is granted,I will exercise the rights granted in accordance with the terms and subject to all the
condit
ions and lit> i tions of the approval.
tcant's or auth r ' d rent's signature Print name
t/u-
Props wner's arute (if required) Print nark Date
'lke SC17t1c �S 7IZ42-1
Case No: PFI2021 00150 Ycrmit fee: aQ'J.av Received by: NIT Date 4/27 2021�
Approved by: �i'l�.Ylf at�. Date: �/�9/20?/ Notified by �_Date: � -_7*2I
City of Tigard 13125 5lV'Hall Bkel. • '1'ikarcl,Ore}on 9?223 • aAew.tigard or.goc • 50,7182421 • Page 2 of 4
1 Edge of Pavam"A
I
Ditch----
Streetlight , ��•—
� j
y
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' "d = j Exist ng 1
£ Driveway
1
ve
1
Ix, ---- - - i
j
e
Poweryti I Q I e ^
a \\\ 95' 1
ijam,,,•---..._ .�.---�.•—•
i , 2e� `doper line""
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Nytlrarrt(FM)
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Scale: 1"=3U
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North arrow Property lines&dimensions Existing utilities locations
(sewer,storm,water) If
S eet&street namesAll/ existing structures
Proposed work Existing curb or edge of pavement Utility&street tight poles
Fxisting Sf W or D/W apron Slope of property Trees
Cin of Tigard • 13125 SW Hall Hlvd. ` Tigard,Oregon 97223 • N%mwtigard-ocgov %3-718-2421 • Puge 4 of 4
F'irrlox about:blank
Flawless Remodeling Service LLC
P.O.Sox 1845 Wilsonville Oregon 97070
CCB 203269 LC8 9828
- For service at:
ACCOUNT 4tpR-IC526 Karn S
Sidewalk estimate8905 SW Avon Q
L Tigard,OR 97224
alxirf"S Proposed by:
8905 SW Avon Ct Agustin Feliciano Madrid
Tigard,OR 97224 Tel: 360-723-0862
fel'pe@flawlessrernodelingservice.com
4/14/2021
We appreciate the oprortulty to bid In ms p'okct The folo0 g propam and went vAl sefxdnle as you request I.
,Tr?c ^.fr ... Prireluislt 'rex tltscourt Total visftslyear Renewal
Construction Price/Visit Tax Discount Total Visits/Year Renewal Annual
ContreLa $2,800.00 $0.00 $0.00 52,800.00 1 $0.00 $2,800.00
Remove city Sidewalk(26x5)and prepare to frame, call for inspection and pour new Sidewalk according to the city
specifications and Cade.
Do not touch the tree roots: raise the level of the new sidewalk.
Including the permit fees
TOTAL FOR THIS PROGRAM ¢2.800.00
TOTAL FOR ALL PROGRAMS $2.800,00
Acceptwxe of Proposal'.5111.a doaph Pwr ert to stars std t1re rest when,the lob is dune.The above priers,spedfkmti and are satisfactory and are hereby
aaepted.Yew are to lb the rlcvk w sp&1W.PaynwrA wha be made as outW*d abow.This proposal Is valid for 30 days "!iW wort to be carvleted In
a worbrxarl3ce dkg to stli lord practice.Any alleratiah or dwWon train above spedkVions hwoMnp eara coag will be executed only Wor wAttw
Nems,and
•tea •--�
Oats
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