PFI2013-00016 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PFI2013-00016
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 05/23/2013
Parcel: 2S111AD00401
Jurisdiction: Tigard
Site address: 8605 SW PINEBROOK ST
Subdivision: PINEBROOK TERRACE Lot: 1
Project: BRITTANY HOMES
Project Description: PUBLIC FACILITIES IMPROVEMENT PERMIT FOR A SEWER TAP
Owner: FEES
Description Date Amount
PFI Permit Fee 05/20/2013 $300.00
PHONE:
Contractor:
STRAUSS EXCAVATING
24175 SW DAVIS RD
HILLSBORO, OR 97123
PHONE: 503-649-8117
FAX:
Applicant:
JEFFLUEDLOFF
24175 SW DAVIS RD
HILLSBORO, OR 97123
PHONE: 503-649-8117
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.
Perm
Sign tture: licant �,� 1 Pr
Signature: (j-� 1
Issued By: 3am
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
City of Tigard
Public Facility Improvement (PFI) Permit
General Information: FOR STAFF USE ONLY
Property Address/Location(s): 56a5 / n%%t�v�5i Engineering (�c
Case No.:
ReceiptNo.: y3'2
Date: ,S`dD/3
*Applicant's Name: 'a e-t'Y"'rf�q Application Accepted By:�
Address: 7_12A7_12A�� S SLJ c(IS — JKa-edOOW Revised 7/1/10
City/State: S�+csLs.Jc�T� Zip: 9 '7 1 ~f O
Primary Contact: � G 644_--C2 1:-t ' REQUIRED SUBMITTAL
q �
Phone:�� C//-y.7 Z-L- Fax:51D?`4 Z-p" L INFORMATION
Professional Engineered Plans are required
for•
Contractor's Name: <-+44-"-5 S E?�� e,
• Street Widening
CCB# S Expiration: / • Subdivision Infrastructure
Address: �9 9 �JS- fG� • D1ain utility line extension:
City/State: �l llf�•^ Zip: !9 3 0 Storm Drain,Sanitary-Tigard
�/ `��' 0 Water-Tigard Water Service Area
Phone:S�� E7 KI?7 Fax: (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).
1:curpin\master\land use application\111,1 app.doex
Description of work: ��✓
Estimated value of work(within the public right-of-way): $
Is work related to a LAND-USE DECISION? YES F-] NO
If so,please specify (MLP,SDR,SUB,etc.) case #:
Is the work related to a BUILDING PERMIT? YESX NO
If so,please specify (BUILDING PERMIT) case#: S l 1
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
DEVELOPMENT ENGINEERING FEES
1. Public Facility Improvement(PFI) Permit:
Part 1: All non-water system improvements
Engineer's estimate X 5% (less$300.00 submittal fee)
Engineer's estimate X 2%Plan Review
Part 2: All public.water system improvements
Engineer's estimate X 12%
Total Permit Fee =Part 1�+ Part'Z
PFI Permit-Fee Exemptions:
There will be no permit fee charged,or,assurance required for the following types of work:
• Sidewalk or driveway repair (less than 20 lineal feet)
• Relocate or replace mailbox
e Ditch cleaning that does not involve regrading.
• Weephole repair
• Curb repair or replacement(less than 20 lineal feet)
• Lawn sprinkler system installation or repair
• Street tree pruning or planting
• Planter strip landscape maintenance
• Test wells
2. Addressing Fee: The fee forrthis service is$50.00 per address.
SAMPLE
Minimum Sketch Requirements
North Arrow Property Lines&Dimension Slope of Property
Street& Street Name(s) 4 Existing Building,Structures Utility&Street Light Poles .
Proposed Work Existing Curb or Edge of Pavement Trees
Existing S/W or D/W Apron Existing Utility Locations (sewer,water,storm)
City of Tigard 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov Page 2 of 4
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 191432 - 05/20/2013
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12013-00016 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 014544 JFLOYD 05/20/2013 $300.00
Payor: JEFF LUEDOFF
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
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