PFI2012-00033 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12012-00033
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 09/25/2012
Parcel: 1 S 125DA04500
Jurisdiction: Tigard
Site address: 6745 SW ALFRED ST
Subdivision: KINGS VIEW Lot: 30
Project:
Project Description: Front ditch fill
Owner: FEES
Description Date Amount
PFI Permit Fee 09/25/2012 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
DAN GRAVER
TIGARD, OR
PHONE:
Total $300.00
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 b e beginning work.
Permittee/Applicant
Signature: "z' ,,
Issued By: 10 OOA &PN/
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12012-00033
Type: Condition Name: Status: Severity:
City of Tigard
Public Faci ity Improvement
• (PFI) Permit
General Information: FOR STAFF USE ONLY
Property Address/Location(s): U-1`4 67) Sud A uYed S (' Engineering
Case No.: 2P 11011 -6 0 0 3 3
Receipt No.: 10 5 k Lo
Date: °I(25 1 1Z
*Applicant's Name: 17)Ci Y1 U✓U•VeX Application Accepted By:
Address: 145 SW A (�-e d- S + Revised 7/1/2011
City/State: Ti a uX d Zip: Q"12'13
Primary Contact: �1 Cjy aA.A ems REQUIRED SUBMITTAL
Phone: `);-Z d• 5 ' 5L" —1 Fax: INFORMATION
E-Mall: Professional Engineered Plans are required
• Street Widening
Contractor's Name: • Subdivision Infrastructure
CCB# Expiration: • Main utility line extension:
0 Storm Drain,Sanitary-Tigard
Address: 0 Water-Tigard Water Service Area
City/State: Zip: (includpo�oneof unincorporated Washington
City and a
Phone Fax Count
"Note:See Engineered Plan
Plans By: Submittal Checklist attached.
Address: For all other work:Submit scaled sketch of the
Ciry/State: Zip: work to be done. (see attached minimum sketch
requirements and provided sketch area).
Phone: Fax:
I:curpin\master\land use application\PFI app.docx
Description of work: (111 i o F'Wm
Estimated value of work(within the public right-of-way): $U300. 00
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 E—
lf so,please specify(BUILDING PERMIT) case#:
City of Tigard 1 13125 SW Hall Blvd,Tigard,OR 97223 1 503-718-2464 1 wwwtigard-or.gov I Page 1 of5
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 188516 - 09/25/2012
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12012-00033 PFI Permit Fee 100-0000-43114 $300.00
Total: $300.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 878638 TLEHRBACH 09/25/2012 $300.00
Payor: Daniel Gruver
Total Payments: $300.00
Balance Due: $0.00
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