PFI2020-00479 V / tr
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
IIIit
I Request for Permit Action ' 2-A/2-/ 4.z),
TIGARD 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 ® City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE ACTION FOR THE ITEM(S) CHECKED(✓):
® CANCE f OID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: PFI2020-00479
116117
Site Address or Parcel #: .44445 SW Errol St ("9-p-cc,)
Project Name: Goalby Sewer
Subdivision Name: N/A Lot #: N/A
EXPLANATION: Per Engineering, applicant applied for 2 PFIs and only 1 PFI is required to
connect both the main house and ADU to sewer in ROW. Please void this
one, thank you. EE PF12OZI —DfOO Lv A✓U Pa—LT /°'9' ,
1/7/2021
Date:
Signature: Cif
Print Name: Lina Smith
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date 0 2/ By ./
Refund Processed: Date /�/� Byzeil7 Invoice Processed: Date By
Permit Canceled: Date 0 4/y/ B Parcel Tag Added: Date By
I:\Building\Forms\Req PermitAction_66923(4.doc
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ity of Tigard PFI#; 202O OD47 _IIING1NIiI RiN(7 DISPAN'I'M1IIiN'I .
TRIM;n I ublic Facilities Improvement (PFI) Permit
PROJECT INFORMATION
f_
UalCJ V1 _....¢ .�lIst a�A TYPE OF WORK
PR peel name: J 7 LL u TYPE 1-Franchroe I1tiLty Nock
Poet description of project: C I? s. 4 it T S I oTZI performed by MC'N,PGIi, or utility
Av N — — i. . 5 it er. f 4 ('/iv, /Yi TYPE 2-ROW alk Sidcv /Driveway CO).
Work performed fur the purpose of
• Sidewalk installanun or repair
• Dnvcway approach installation and repair
SITE INFORMATION I L to ,/ • Sanitary sewer lateral installaton aid
tl`e 1 Vealn fine rap
location (address if available): SW �+ y�T.
❑ TYPE 3-Full Scale Development Week
.' &At a OD performed with lanai use approval which
!= msludes any of the following:
• Subdivisions or Pa:toons
APPLICANT INFORMATION • Street widening
. 1 • Mainline installation for sanitary sewer,
Name:_ J A4Sv.•� C \101 storm sewer,Tigard ...parer, and Tigard
Mailing address: `1,v441D S41( C rf 0 1 S4-• cater senticc area
�J 7Z23 =] TYPE 4-Scull CeU Technobq
City/Stan: `S[t,dLrd QR Lip: J 11 TYPE5 Tigard Triangle
Phone: GJ`tl'Zj - )�3y - 7y�3
Email: Q'p 1 hQ 11 1M111�- 6WI Pl title_ NOTE! Type I and 2 applications may hr
J J emaikd to rotvpermruIjigasd-or Xuv.
Contact name:
Phone: Email:
CONTRACTORp � INFORMATIp
(V NI ❑ Same as applicant
Name: OvvIoXCO ( .1 c-c ) Cal Number: -1 (1.5S
Mailing address: L{UfaLA S. E(.Li -i- ?falrlfitri4ate. 1(�lQto\1 U✓N f OQ Zip: ct1o1I
--
Phone: COI 44120 - ID S-Q� Q Email: i CSS onst►, ()Old 1( -CAW)ENGINEER INFORMATION c�
Name: 71P e
Mailing address: -_ City/State: Zip:
Phone: Email:
ADDITIONAL INFORMATION
Si Estimated value of work is required(if over$5,000):$ Ur sfrOd (within the public right-of-way)
Is work related to a LAND USE DECISION? 0 Yes L�No Case number:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Or gon 97223 • wwwtigard-or.gov • 503718.2421 • Page 1 of 4
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APPLICANTS
NOTE: Person sp vilicd as"Applicant"shall he designated"Permletee"and shall provide financial assurance for
work,It required by(he city pursuant to TM(: 15.04.140.
• N nh the rarllNaac tit t utdas.'rnting pttnuant to a valid franchise it hems,loth the tin-of Typrd,when the wvw and the applicant
an- I ct k,lice applicant aunt he the purchaser of record or a lnsre in ponesaiun with written authorization from the owner
of an atrnt rot the tmver 'ITe rwirr must sign this application in the apace provided or submit a written authorization wish this
applrutwn. fnndusnl nr Iacenstd litihtrs are nut required to obtain the owner's signature on the application.
I, 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,1 will exercise the rights granted in accordance with the terms and subject to all the
conditions and limitations of the approval.
je S5 e'rlowt ,Z/g/2-0
pplicant's or authorized agent's signature Print name Date
Property owner's signature(if required) Print namr Date
• • •r • SI 111 t J.11\1_1'
case tre1 PFI2020-00479 permit fee12/9/2020
Acceirf�by: AL� � Drtte:
Approved by: Dates Notified'bys_ Darr.
City of Tigard • 13125 SW Ha11 Bltd. • Tigard,Oregon 97223 • awxtigatdocgv • 503-718-2421 • Page 2 of 4
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