PFI2013-00040 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
• COMMUNITY DEVELOPMENT Permit#: PF12013-00040
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 10/22/2013
Parcel: 1 S 125DA07100
Jurisdiction: Tigard
Site address: 9465 SW 70TH AVE
Subdivision: KINGS VIEW Lot: 57
Project: Woolard
Project Description: Replace driveway approach at 9465 SW 70th Ave.
Owner: FEES
Description Date Amount
PFI Permit Fee 10/22/2013 $300.00
PHONE:
Contractor:
TOWER CONCRETE
6720 SW ALFRED ST., APT. B
TIGARD, OR 97223
PHONE: 503-740-8445
FAX:
Applicant:
JACK WOOLARD
9465 SW 70TH AVE.
TIGARD, OR 97223
PHONE:
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: T
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): Engineeringg r`
Case No.: 102.0(3 -00090
6 w 7d A �i Fee: 11JJ
Q 7 •w'
r Receipt No.: ��3 6�9
*Applicant's Name: \)(16< UJ I l�� Date: k017--z-113
ddress: Application Accepted: i ?� By:�
City/State: I j?c7t v-, ) Zip: c�TZ2-�)
Primary Contact: REQUIRED SUBMITTAL
INFORMATION
Phone: Fax: IF
E-Tlail: Professional Engineered Plans are required
for:
T ff' C_ Street Widening
e>
Contractors Name: 1pw .r CD +`t 'L >0A" V a ,-r
• Subdivision Infrastructure
CCB# I ! 1 Z J Expiration: 7 o l S • Main utility line extension:
Address: 6 7 Z 0 s �� �� 0 Storm Drain,Sanitary-Tigard
0 Water-Tigard Water Service.Area
City/State: i c •- zip: 1 -7 (includes Durham,King City and a
portion of unincorporated Washington
Phone: Sy3 `i Fax: -'U '4 County)
'Note:See Engineered Plan
Plans By: Submittal Checklist attached.
Address: For all other work: Submit scaled sketch of the
Cite/State: Zip: work to be done. (see attached minimum sketch
phone: Fax: requirements and provided sketch area).
I pdatcd.6;'24j 2ol 1
I:\Cl RPI.N\Mastcrsl hand t xc ApplicationsTublic 1�acihn
Description of work: a r— � \�\rte TFPnt tl L Impmccment.dOCN
Estimated value of work(within the public right-of-way): $ q CL ,
Is work related to a LAND-USE DECISION? YES F-] NO Pf
If so,please specify (MLP, SDR, SUB,etc.) case #:
Is the work related to a BUILDING PERMIT? YES El NO
If so,please specify (BUILDING PERMIT) case #:
CM,of Tigard 13125 S\X'Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-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"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 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 0 C 1 120 3
e��l
%pplicant/Authorized Agent's Signature Owner's Signature
Owner's Signature Owner's Signature
Cit} 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
g 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 193615 - 10/22/2013
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12013-00040 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 142509 TLEHRBACH 10/22/2013 $300.00
Payor: Tower Concrete LLC
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
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