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PFI2021-00192 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 4 Request for Permit Action elf-775-118 13125 SW Hall Blvd. • Tigard, Oregon 97223 . 503-718-2439 • www.tigard-or.gov 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: ❑ Owner ❑ Applicant ❑ Contractor Q City Staff Check(V)one REFUND OR Name: INVOICE TO.• (Business orindividual) Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): © CANCEL/VOID PERMIT APPLICATION. ❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). Permit#: PF12021-00192 Site Address or Parcel#: 9405 SW Edgewood Project Name: Mitchell Sewer Subdivision Name: Lot#: EXPLANATION: Duplicate permit of PF12021-00227 Signature: Date: 6/22/2021 Print Name: Agnes Linddr Refund Policy 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 • Not more than 809/6 of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. • ' OFFICE USE ONLY Route to Sys Admin: Date I 13y I Route to Records: Date 6 yi B Refund Processed: DateAf, I By 4,C) Invoice Processed: Date B Permit Cancelcd: Date !k&""Z2-0j By dO I Parcel Tag Added: Date B C\Building\Fua s\RegPevriLAction_1 0518.doc F a City of Tigard i! PFI#:2021-00192 ENGINEERING DFPARTMF.NT 61 2' 4 a Public Facilities Improvement (PFI) Permit PROJECT INFORMATION SLla 91Z Lwfl Iasfwllr�'tw� TYPE OF WORK Project name: ❑ 'I'YPC 1-Franchise Utility Work Brief description of project: (OW(:' �M 5st lre IA.N►t- agency performed 'PGE, or utility TYPE 2-ROW Sidewalk/Dr sway/Sewer Work performed for the purpose of. • Sidewalk installation or repair • Driveway approach installation and repair SITE INFORMATION 9405 t • sanitary sewer lateral installation and 8 Location (address if available):480% 5��.Ct 0�CyuJ main line tap ❑ TYPE 3-Full Scale Development Work �5aaa tiOfl- (�'laa3 performed with land use approval which includes any of the following: • Subdivisions or Partitions APPLICIA(\NETT IpNFORMATIIOpNp • Streetwidening Name: ' "' �1 `•^(�' V \""� • Mainline installation for sanitary sewer, storm sewer, Tigard water, and Tigard Mailing address: q y 1J S � �dear�d water service area City/State:`T tai OA Zip:q -7A oa 3 ❑ TYPE 4-Small Cell Technology Phone: 503 {I - �C1 c5I Oa- 5-b b- 5-77- 'j-&1 3 ❑ TYPE 5-Tigard Triangle Email:rrt+ltoIC*%V"rv, U>VOC44 Phone: NOTE Type 1 and 2 applications may be emailed to rowpurmiwa.4 ,r..o-. Contact name: Phone: Email: CONTRACTOR INFORMATION ❑ Same as applicant Name•TOr^\-U&t-L°- CG�t `s�'n ,Ll-nnGCCB Number: a(3oa I o� Mailing address: �� Caa.nP�tttS P��+�i ity �e: ��1\�loor¢c��(a12 Zip: 9 1� Phone:50':�o -6 FSO-1�6q 9-1 Email:' ytCQp'�•Se2WVwr+-%�5• COm ENGINEER INFORMATION Name: CLO/_ 13051 (N ZS Mailing address2960st (LTJ ayos No N City/State: HILLSBG2Df 0R zip: 91 �Z Phone: 5-63-W- "R191f? Email: WWW. CtA(;13usriMS uG, COM ADDITIONAL INFORMATION r �j Estimatedvalue of work is required(if over$5,000):$ 1�t 1y� (widtin the public tight-of-way) Is work related to a LAND USE DECISION? ❑Yes 03'N'o Case number: Cityof Tigard • 13125 SW IbE Blvd. • Tigard,Oregon 97223 6 www.tigar(i-or.gov • 503-718-2421 • Page 1 of 4 APPLICANTS NOTE: Person specified as Applicant" shall be designated"Permittee"and shall provide financial assurance for work,if required by the city pursuant to TMC 15.04.140. • With the exception of a utility operating pursuant to a valid franchise or license with die City of Tigard,when the owner and the applicant are different people,the applicant must be the putchaser of record or a lessee in possession with written authorization from the owner or an agent of the owner. The owner must sign this application in the space provided or submit a written authorization with this application. Franchised or licensed Utilities are not required to obtain the owtici s signature on the application. 1,the applicant,certify that: • To the best of my knowledge, all the information provided within this application package is complete and accurate. • The above request does not violate any 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 conditions and limitations of the approval. :lI plicanes or authorized agent's signature Print name Date Property owner's signature (if required) Print name Date • Case No: PF12021-00192 Permit fee: Received by:AL Date: 5/25/2021 Approved by: Date: Notified by: Date: City of Tigard • 13125 SW Hall Bhd. • Tigard,Oregon 97223 • wwwtigard-ongov • 503-718-2421 • Page 2 of 4 y Y .. a f icA Yl Z;f G�'J Fla+li 4FY k( S Or•f�rC. R' S�u4�?. tiR14