PFI2013-00025 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12013-00025
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 07/22/2013
Parcel: 2S111 CB01738
Jurisdiction: Tigard
Site address: 10400 SW HOODVIEW DR
Subdivision: HOOD VIEW NO.2 Lot: 37
Project: Chwirka Driveway Approach Replacement
Project Description: Adjacent to 10400 SW Hoodview Dr., replace two concrete driveway approaches.
Owner: FEES
Description Date Amount
PFI Permit Fee 07/22/2013 $300.00
PHONE:
Contractor:
CUSTOM CONCRETE CONSTRUCTION
4510 SW POPLAR LN.
PORTLAND, OR 97225
PHONE: 503-628-4505
FAX:
Applicant:
STEVE CHWIRKA
10400 SW HOODVIEW DR.
TIGARD, OR 97224
PHONE: 503-620-7777
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 before beginning work.
Permittee/Applicant /
Signature: i
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
RECEIVED
City of Tigard JUL 15 2013
r Public Facility Improvement CITY OF TIGARD
TIGARD (PFI) Permit PLANNING/ENGINEERING
General Information: FOR STAFF USE ONLY
Property Addre/ss/Loocation(s): Engineering 2
m �0 61le Case No.:
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Fee: V 3 00.00
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9141[/ Receipt No.:*Applicant's Name: J ✓ y� � 1110K� Date:
Address: ,V a/ ✓ tw aae Application Accepted: -11141-;By:
City/State: Zip:
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Primary Contact:,
� �% G/Ta/,Q�� REQUIRED SUBMITTAL
��^^ INFORMATION
Phone:-�G `(D2� -7,777,�q Fax:
E-Mail: e�k'1 Professional Engineered Plans are required
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Contractor's Name: �G7>.vt L' /G G`"S�IP6G/�^L ' Street Widening
q/ [� . Subdivision Infrastructure
CCB# /b / � Expiration: / • :Main utility line extension:
Address: y.3�/O �� fon 14/� L.� uC 0 Storm Drain,Sanitary r Service-Tigard
(/�� 7Z-Z S 0 Water-Tigard Wate .Area
City/State:�AIR-1/� . ///�6 Zip: ,?, (includes Durham,King City and a
pportion of unincorporated Washington
Phone: Fax: 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).
Update&6/24/20 1 3
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Description of work: C 'F Cn*f el-1 n C' t lmprorement.docs
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Estimated value of work(within the public right-of-way): $
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
If so,please specify(BUILDING PERMIT) case #:
City of Tigard 1 13125 SXX'Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page I 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 im sed upon the subject prone tyr
♦ 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.
♦ All 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 20 13
C�"
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 503-718-2464 1 www.tigard-or.gov I Page 2 of 5
CITY OF TIGARD RECEIPT
Ig 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 192327 - 07/22/2013
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12013-00025 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
Check 2623 TLEHRBACH 07/22/2013 $300.00
Payor: Steve Chwirka
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
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