PFI2013-00033 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
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_ COMMUNITY DEVELOPMENT Permit#: PF12013-00033
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 09/05/2013
Parcel: 1 S134ABO2600
Jurisdiction: Tigard
Site address: 11313 SW IRONWOOD LP
Subdivision: ENGLEWOOD Lot: 83
Project: Mike Gaige
Project Description: Adjacent to 11313 SW Ironwood Loop. Construction of a sewer line to existing home which includes
replacement of existing driveway approach.
Owner: FEES
Description Date Amount
PFI Permit Fee 09/05/2013 $300.00
PHONE:
Contractor:
ENVIRO TECH HOME INSPECTION&CONSTRUCTIC
3530 SE 151 ST AVE
PORTLAND, OR 97236
PHONE: 971-400-6848
FAX:
Applicant:
MIKE GAIGE
3530 SE 151TH AVENUE
PORTLAND, OR 97236
PHONE: 971-400-6848
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:
Issued By: 4,�11
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: 192986 - 09/05/2013
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12013-00033 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 155605 CCAINES 09/05/2013 $300.00
Payor: Mike Gaige
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): _3 S IA/ ��' �✓`="' 6--,p Engineering FE I ,�3"D� 3
.� Case No.:
Fee:
Receipt No.:
*Applicant's Name:/ /���� �/'���e Date: Cii(E41a>
Address:S.5-30 5E Application Accepted: S :!7 By:
City/State: 69't/D , CR. Zip: / �.3 4�-,
Primary Contact:11l//lE 491111 C q REQUIRED SUBMITTAL
I
Phone: l 71` el�"<OtFY8 Fax: FNFORMATION
E-Mail: �. Q t�Sd�C77C.AIS q�y�l C.C,. +`� Professional Engineered Plans are required
for:
Contractor's Name:/)7,AC ��► E • Street Widening
• Subdivision Infrastructure
q
CCB# /!6 0) nExpirati :l �/ • Main utility line extension:
Address: o�s 3 $F / S 1 si'A✓ �(Z 0 Storm Drain,Sanitary—Tigard
0 Water—Tigard Water Service Area
City/State: ./6 c�R� zip: 9 72-3 (includes Durham,King City and a
G Y V V Fax. portion of unincorporated Washington
Phone: 7/—y,�- 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).
Updated 6/24/2013
I:\CURPLN\Masters\Load Use Applications\Public Facility
Description of work: Improvement.docs
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 SW Hall Blvd.,Tigard,OR 97223 503-718-2464 1 www.tigard-or.gov I 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"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
(1)ctaded Submittal Requirement Information sheets can be obtained,upon request,for all types of Land Use 1pplications.)
BY SIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT:
• The above request does not violate an=deed restrictions that may be attached to or imposed upon the subject property.
♦ 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 6t-Pr6>1 Ci C- ,20
A licant/Authorized Agent's Siknitture Owner's Signature
Owner's Signature Owner's Signature
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.dprd-or.gov I Page 2 of 5
SKETCH AREA:
I
Co�
City of Tigard 13125 SW Hall Blvd.,Tigard,OR 97223 503-718-2464 www.fiprd-or.gov Page 5 of 5
SAMPLE SKETCH:
Edge of Pavement
Ditch
Streetlight I — —•—•—•—•—•—•—C—•—
• e Rauf Drain
1 I -T r— a
<>�M I
� I o
' T-Propos d'S�nr`erTine'-
N Existing House
Existing 1
Driveway ,
ai
vi I 1
L
aI I vim`
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Icr,9 1
>i I 1
0
Existing Shop
I '
� J
Power ole .
P I olo
0-
95'
-------Trop F Lne----------
� I
iI Fire Hydrant(FH)
� � I
Scale: 1"=30'
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Minimum Sketch Requirements(Put"n/a"if Not Applicable):
North Arrow Property Lines&Dimension Slope of Property
Street&Street Name(s) 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 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 4 of 5