PFI2012-00036 S'.
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CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
n COMMUNITY DEVELOPMENT Permit#: PFI2012-00036
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 10/09/2012
Parcel: 1 S134C605400
Jurisdiction: Tigard
Site address: 11125 SW TONY CT
Subdivision: ANTON PARK Lot: 16
Project: Flax driveway approach
Project Description: Remove and repour driveway approach as part of driveway replacement.
Owner: FEES
Description Date Amount
PFI Permit Fee 10/09/2012 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
GERARDO HERRERA
7866 SE JEFFERSON ST.
MILWAUKIE, OR 97267
PHONE: 503-891-5947
Total $300.00
Please sign below to indicate acceptance of conditions and tum a copy with the proposed work schedule along with names and contact
information of responsible parties before beginning work.
Permittee/Applicant
Signature:
7WIssued By: XZZ
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12012-00036
Type: Condition Name: Status: Severity:
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 188705 - 10/09/2012
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12012-00036 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 30932G TLEHRBACH 10/09/2012 $300.00
Payor: Gerardo R Herrera
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
City of Tigard
Public Facility Improvement (PFI) Permit
General Information: FOR STAFF USE ONLY
Property Address/Location(s): //4M $W 7D/!r Cf Engineering
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Case No.- -i 2_0iZ—0003y
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Receipt No.: I -105
// Date: I C q 1 2
*Applicanes Name: �ef'L?tlo 69errern Application Accepted By:
Address: 7y( se ze e rserl st Revised 7/1/10
City/State:./1/((MJUUkte or Zip: 9 (07
PrimaryContact: QYV I-cey REQUIRED SUBMITTAL
Phone: B05—8V �V`IM Fax:&! 9;1/- 9-Z5-53-25. INFORMATION
Professional Engineered Plans are required
Contractor's Name: Cncj2rc4 for:
CCB#If AT 3d2 Expiration: Ze-Ad-<</ : Street Widening
p Subdivision Infrastructure
Address: �oG S&Te�f�Flr.So✓) gt • Main utility line extension:
City/State:,4�a Uk—r f7 .D Y Zip: 0 Storm Drain,Sanitary-Tigard
ey �q qqtt 0 Water-Tigard Water Service Area
Pho1e: .;_03' 89/—59//71 Fax: ���� g�Jr'—v�0`•! (includes Durham,King City and a
portion of unincorporated Washington
County)
Plans By:
**Note:See Engineered Plan
Address: Submittal Checklist attached.
City/State: Zip: For all other work:Submit scaled sketch of the
Phone: Fax: work to be done. (see attached minimum sketch
requirements and provided sketch area).
Description of work pproo c!4 IDrl f Q r�a I:curpin\master\land use application\PFl app.docr
f?fN ri✓ PG9a f
Estimated value of work(within the public right-of-way): $ 01.f40d
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
If so,please specify(BUILDING PERMIT) case#:
*NOTE:Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for the work.
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 1 of 4
SKETCH AREA: 5W 7-e/7y
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City of Tigard 13125 SW Hall Blvd.,Tigard,OR 97223 503-718-2464 www.tigard-or.gov Page 4 of 4