PFI2013-00038 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
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COMMUNITY DEVELOPMENT Permit#: PF12013-00038
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 09/25/2013
Parcel: 2S103DD01700
Jurisdiction: TIGARD
Site address: 10990 SW GARDEN PARK PL A
Subdivision: GAARDE PARK Lot: 1
Project: Wrench Property Sidewalk and Approach
Project Description: At 10990 SW Garden Park PI., repair sidewalk and driveway approach. Street trees have damaged
concrete in several places.Tree removal approved under TRE2013-00032.
Owner: FEES
Description Date Amount
PFI Permit Fee 09/25/2013 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
RICK HEISLER
P.O. BOX 42566
PORTLAND,OR 97214
PHONE: 503-771-7971
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 �l
Signature:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
CITY OF TIGARD RECEIPT
a 4
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 193216 - 09/25/2013
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12013-00038 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 015416 TLEHRBACH 09/25/2013 $300.00
Payor: Ervin L Latincsics
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): 19990 SW Garden Park P1 Engineerin
Tigard, OR. Case No.: 1I UG'i 3 -- 0003S
Fee: dsop.+o
Receipt No.: l9 ).7
*Applicant's Name: Carolyn Summers Date:__`fl 2S I 1
Address: 10990 SW Garden Park Pl. 2-S I
Application Accepted: `�11 1 3 By-.41/
City/State: Tiga rd, OR. Zip:
Primary Contact: Rick Heisler REQUIRED SUBMITTAL
Phone: 503 771-7971 Fax: INFORMATION
E-Mail: metrosidewa lkC�sn.eom Professional Engineered Plans are required
• Street Widening
Contractors Name: Metro Sidewalk Repair . Subdivision Infrastructure
CCB# 47503 Expiration: • Main utility line extension:
Address: PO BOX 42566 0 Storm Drain,Sanitary-Tigard
Portland OR• 97214 0 Water-Tigard Water Service area
City/State: Zip: (includes Durham,King City and a
Phone: 503 771-7971 Fax: 503 771-7862 portion of unincorporated Washington
County)
"Note:See Engineered Plan
Plans By: Rick Heisler—Metro Sidewalk Repair Submittal Checklist attached.
Address: same 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:6/24/3)13
l:\CURP].N\Masten\land use Applicatums\Public pacdity
Description of work: driveway and sidewalk repair Imptovenwnt.docx
due to right of way tree damage
Estimated value of work(within the public right-of-way): $ 4,000-00
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,tigaid-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
(Detailed Submittal Requirement Infom-iation 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 impQsed uMn the subject propeM,
♦ 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 _ Y' � Al C�' 20
pplicant/ thorized Agent's Signature Owner's Signature
tiv�r�n�c
�u hcf,; { �> �}'�,�y�� ✓ Owner's Signature
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City of Tigard 1 13125 SW Hall Blvd.,Tigard, OR 97223 503-718-2464 1 www.tigard-or.gov I Page 2 of 5
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City of Tigard 13125 SVG'Hall Blvd.,Tigard, OR 97223 503-718-2464 1 www.tigard-or.gov I Page 5 of 5