PFI2013-00028 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12013-00028
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 07/22/2013
Parcel: 2S 112AD00700
Jurisdiction: Tigard
Site address: 14830 SW 72ND AVE
Subdivision: BONITA GARDENS Lot: 4
Project: Pioneer Waterproofing Co. sidewalk and driveway repair
Project Description: New sidewalk and driveway aprons.
Owner: FEES
UNION CENTRAL LIFE Description Date Amount
TREASURY SERVICES PFI Permit Fee 07/22/2013 $300.00
ATTN: DIANE THOMAS PFI Permit Fee 07/22/2013 $260.00
PO BOX 888
CINCINNATI, OH 45240
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
MICHAEL CRAWFORD
14830 SW 72ND AVE.
TIGARD, OR 97224
PHONE: 503-232-9020
Total $560.00
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:
Issued By:
i
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 192335 - 07/22/2013
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12013-00028 PFI Permit Fee 100-0000-43114 $260.00
PF12013-00028 PFI Permit Fee 100-0000-43114 $300.00
Total: $560.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 712224 TLEHRBACH 07/22/2013 $560.00
Payor: Michael A Crawford
Total Payments: $560.00
Balance Due: $0.00
Page 1 of 1
City of Tigard
y Public Facility Improvement
s (PFI) Permit
General Information: r} FOR STAFF USE ONLY
Property Address/Location(s): lggT>o SW -7zo 7p✓ii Engineering ' 1�` Z�
D2. 9 7yZ� Case No.:
Fee: it560.00
/' Receipt No.: 02.33
*Applicant's Name:�10 �2 W �yf l' Co • Date:
1 1 Address: 30 SW 7V`0 AV,:— Application Accepted: 7 22 By:
City/State: '_r% A 0W (,t2• &j7ZV1 zip:
Primary Contact:j'�1&"tQ "AW 0jou REQUIRED SUBMITTAL
INFORMATION
Phone: S�3-Z3Z�nZo I�ax: 5713-Z3`f-�7b3
E-Mail: c1Q WA20AV Professional Engineered Plans are required
for:
'ro t • Street Widening
Contractor's ffN��,�ame: r'll-mss I11•+�. �I`�• (fes. I +5' . Subdivision Infrastructure
CCB# DOP&' Expiration:-7 'lain utility line extension:
Address3.0•19D'A Z74Z` 0 Storm Drain,Sanitary-Tigard
JJ 0 Water-Tigard Water Service.Area
nn
City/State: Poi--r AHO. off• Zip: IZZ470 (includes Durham,King City and a
,146/1 q portion of unincorporated Washington
Phone: J�3 7 1.50 I ax:So3-4 -/3&e County)
Plans By: P;,>P�,t W �-�n�� -i.�•s G� "Note:See Engineered Plan
Submittal Checklist attached.
Address:_�a'g- �ZNr� �Vn+ C� For all other work:Submit scaled sketch of the
City/State: �f ` 1 � 0l� Zip:_ [7Z7i� work to be done. (see attached minimum sketch
Phone: 5.D3-237 0?10 Fax: S'7TC^ZTc1—476,3 requirements and provided sketch area).
UpdatW:6/24/2013
1:\CURPI.N\Masters\land Cce Applications\Public I-aeiliti
� Imprurcment.do�cc
Description of work:P&J ol4stway
Estimated value of work(within the public right-of-way): $
Is work related to a LAND-USE DECISION? YES NO E]
If so, please specify (MLP,SDR, SUB, etc.) case #: ZoI;S
Is the work related to a BUILDING PERMIT? YES❑ NO
If so, please specify (BUILDING PERMIT) case #:
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 www.dgard-or.gov Page 1 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"Applicane'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 Informsttion sheets can he obtsdncd,upon request, for all n1pes 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 imposed upon the subject property.
♦ If rhe 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 starements in the plot plan, attachments, and exhibits transmitted herewith, are true; and the
applicants so acknowledge that any pernur 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 Z� daN,of 20�
Applicant/Authorized Agent's Signature Owner's Signature
Owner's Signature Owner's Signature
Cin' of Tigard 13125 S\C/ Hall Blvd.,Tigard, OR 97223 303-718-2464 I xvww.tigard-ongov Page 2 of 5
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