PFI2012-00019 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12012-00019
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 06/04/2012
Parcel: 2S111ABO8900
Jurisdiction: Tigard
Site address: 9395 SW VIEW TER
Subdivision: PENROSE TERRACE Lot: 34
Project: Jordan driveway/sidewalk replacement
Project Description: Replacing driveway and 20 lin ft of sidewalk
Owner: FEES
Description Date Amount
PFI Permit Fee 06/04/2012 $300.00
PHONE: Customer Deposit 06/04/2012 $750.00
Contractor:
PHONE:
FAX:
Applicant:
DUSTIN TOWER
6720 SW ALFRED ST
TIGARD, OR 97223
PHONE: 503-740-8445
Total $1,050.00
Please sign below to indicate acceptance of conditions and return a copy with the proposed work schedule along with names and contact
information of responsible parties before beginning work.
Permittee/Applicant
Signature:
Issued By: (keo
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 186993 - 06/04/2012
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12012-00019 PFI Permit Fee 100-0000-43114 $300.00
PF12012-00019 Customer Deposit 100-0000-22000 $750.00
Total: $1,050.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Debit Card 123063 HWATKINS 06/04/2012 $1,050.00
Payor: Dustin Tower of Towner Concrete LLC
Total Payments: $1,050.00
Balance Due: $0.00
Page 1 of 1
RECEIVED
JUN 0+{ 2012
City of Tigard
®
Public Facility Improvement CITY OF TIGARD
PLANNING/ENGINEERING
(PFI) Permit
General Information: FOR STAFF USE ONLY
Property Address/Location(s): 9 315 V,-e.,,, Tear- Engineering
Case No.:
Mt Qr Receipt No.:
t-To
D Date:
*Applicant's Name: To Tor-��I\ Application Accepted By:
Address: (13 IS -,L j V i4w Tyri-s Revised 7/1/2011
City/State: T`ctcA 00 Zip:4 7,?-z-
%�j
r /� ��
Primary Contact ith w► To w�✓ LT�7 REQUIRED SUBMITTAL
INFORMATION
Phone: 503 6_31- 0/ 11 Fax:
E-Mail: Professional Engineered Plans are required
for:
/ 1 • Street Widening
Contractor's Name: OW4?(_ Lo �crcly_ LLC pbst.n �� . Subdivision Infrastructure
CCB# 19S 12-5E. iration: 9-.30" .3 • Main utility line extension:
Address: G / Z 0 S w f't 0 Storm Drain,Sanitary-Tigard
0 Water-Tigard Water Service Area
City/State:�i g r-a+( Zip: 9 7 Z Z 3 (includes Durham,King City and a
Phone: b3 7 y C) - S�I-tS Fax: portion of unincorporated Washington
County)
"Note:See Engineered Plan
Plans By: Submittal Checklist attached.
Address: For all other work:Submit scaled sketch of the
City/State: Zip: work to be done.(see attached minimum sketch
Phone: Fax: requirements and provided sketch area).
I:curpin\master\land use application\PFI app.docx
Description of work: Pe 1)I -C��•P E)r � ••-Q_1.�C-�j
Apps ed -,c en A 2cS 4t ,
Estimated value of work(within the public right-of-way): $ 7-"__700
Is work related to a LAND-USE DECISION? YES [:] NO
If so,please specify(MLP,SDR, SUB, etc.) case#:
Is the work related to a BUILDING PERMIT? YES❑ NO 0
If so,please specify(BUILDING PERMIT) case#:
City of Tigard 1 13125 Shy/Hall Blvd.,Tigard, OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 1 of 5
APPLICANTS:
To consider an application complete,you will need to submit ALL of the REQUIRED SUBMITTAL ELEMENTS as described on
the front of this application in the"Required Submittal Elements"box.
NOTE: Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for work.
*When the owner and the applicant are different people,the applicant must be the purchaser of record or a lessee in possession with
written authorization from the owner or an agent of the owner. The owner(s)must sign this application in the space provided on the
back of this form or submit a written authorization with this application
(Detailed Submittal Requirement Information sheets can be obtained,upon request,for all types of Land Use Applications.)
BY SIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT:
♦ The above request does not violate any deed restrictions that may be attached to or imposed upon the subject property.
♦ If the application is granted,the applicant will exercise the rights granted in accordance with the terms and subject to all the conditions
and limitations of the approval.
♦ X11 of the above statements and the statements in the plot plan, attachments, and exhibits transmitted herewith, are true; and the
applicants so acknowledge that any permit issued,based on this application,may be revoked if it is found that any such statements are
false.
♦ The applicant has read the entire contents of the application,including the policies and criteria,and understands the requirements for
approving or denying the application.
SIGNATURES of each owner of the subject property.
DATED this day of Ton Q- 120 i 7—
Applicant/Authorized
Applicant/Authorized Agent's Signature Owner's Signature
Owner's Signature Owner's Signature
City of Tigard 1 13125 SW Hall Blvd.,Tigard, OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 2 of 5
� o
c cT c
ao
c o
4+
x
v v
M
N
N
N
'G
r
b0
Z � -n
M n p y
A N
N M
W �
z o
U ="
H �
0