ROW2013-00026 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT \/ 0 1 0 I
VVV
Request Permit Action 3/5/3
T i G A It I) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor d City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State /Zip:
Phone No.: i
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
i 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).
❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: RoVJ 201 -- 00026
Site Address or Parcel #: 5E6694
Project Name: 0\111 loo- -u,ral
Subdivision Name: Lot #:
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EXPLANATION: /?,�p,�f Ga- ,rc.,� .t ip e.4:.5 .�2 i i 1
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Signature: il 7 Date: -3. 3
Print Name: C - i e ,. ' I
Refund Policy
1. The Director or Building Official may authorize the refund of
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80"/0 of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2 -4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to S s Admin: Date B , Rte to '- .. Admin: Date 3 • ' ii7
Refund Processed: Date /✓O FEES Br ;DI" Invoice Processed: Date By
Permit Canceled: Date 3 /2S/j 3 By / -- Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \forms \RegPemritAction.doc Rev 05/25/2012
City of Tigard
Application for Work in the Right -Of -Way
TIGARD ROW Permit
Property Address /Location(s): 11745 SW Pacific Hwy 5EG 69 FOR STAFF USE ONLY
Right -of -Way
p
NW Natur
Case No.: mv\i2o l?)- 6602.6
*Applicant's Name:
Address:
220 NW 2nd Ave Application Accepted: 3 1 3 By: i��
Portland, Or 97209 Application Reviewed: 3 ° /1�'6By:
City/State: Zip:
$300.00 Application Fee Due: Yes ❑ NoX
Primary Contact: Chris Flu
503 - 226 -4211 x4398 503 - 273 -4822 Applicant Notified:
Phone:
Fax:
Email:
ctf nwnatural Receipt No.:
SAME AS ABOVE REQUIRED SUBMITTAL
Contractor's Name: INFORMATION
CCB# Expiration: • Application form, completed and signed
Address: • Submit one (1) copy of scaled sketch of
City/State: Zip: the proposed work to be done
Phone: Fax:
• Submit one (1) copy of traffic control
plan
Email:
Professional Engineered Plans are required
Plans By: NW Natural for:
Address: • Street Widening
City /State: Zip: • Subdivision Infrastructure
Phone: Fax:
• Main utility line extension
Small: 1:curpin \mas[ers \land use npplicauons \row app.docx I Rev. 7/19/12
Description of work: Lower 1" Poly Service from 0 +06 to 0 +20 to clear New Storm Line. Trench Type Construction
approximately 26' of excavation
Estimated value of work (within the public right -of -way): $ 65.00
Is work related to a LAND -USE DECISION? YES 151 NO ❑
If so, please specify (MLP, SDR, SUB, etc.) case #: Tigard warMart
Is the work related to a BUILDING PERMIT? YES D NO p
If so, please specify (BUILDING PERMIT) case #:
Ch Flu °"°"'°'° "°°`" 03/13/2013
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Signature of Applicant /Permittee: Date:
Print Name: Chris Flu Title: Engineering Coordinator
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A 1 1
City of Tigard I 13125 SW Hall Blvd., Tigard, OR 97223 I 503 - 718 -2464 I www.tigard - or.gov