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PFI2013-00035 f CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT e COMMUNITY DEVELOPMENT Permit#: PF12013-00035 Date Issued: 09/12/2013 9 . a 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Parcel: 1 S135DCO2401 Jurisdiction: Tigard Site address: 11795 SW 91ST AVE Subdivision: NORTH TIGARDVILLE ADDITION Lot: 63 Project: Connect New Catch Basin Project Description: Connect new catch basin to existing concrete basin in front of 11795 91 st Avenue Owner: FEES DONNA KACHELMEYER Description Date Amount 11795 SW 91ST AVE PFI Permit Fee 09/12/2013 $300.00 TIGARD, OR 97223 PHONE: Contractor: RAYMOND ANTHONY SCHWAHN 16111 S REDLAND RD OREGON CITY, OR 97045 PHONE: 503-631-3957 FAX: Applicant: RAYMOND SCHWAHN 16111 S REDLAND RD OREGON CITY, OR 97045 PHONE: 503-631-3957 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: 2 Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12013-00035 Type: Condition Name: Status: Severity: .. City of Tigard a Public Facility Improvement (PFI) Permit General Information: FOR STAFF USE ONLY Property Address/Location(s): �/ 7�/�� S1yjSt /9ve Engineering --T d4j /_L2arA_._D-12_____-97 Z Z_3 Fee: Receipt No. *Applicant's Name:O"n/^ G�h Q/ .✓ Date: Address: j/ 1Tdr S 1.J 9f/ SE &U42, Application Accepted: By:,Y City/State: Q Zip: S 7 -7Z ;? Primary Contac _ REQUIRED SUBMITTAL INFORMATION Phone:_ c_3 — �q - 0 J.�� Fax: E-Mail: v.C, WL4ya 140% Professional Engineered Plans are required for: /1. SL,"w4a l • Street Widening Contractor's Name: owt,t,ld A. ,t1=�a�J +-� � • Subdivision Infrastructure CCB# J 1..�� Expiration: • Main utility line extension: Address: �Ojl j ��►A-�'� /1L1 0 Storm Drain,Sanitary—Tigard 0 Water—Tigard Water Service Area City/State: 6 4=_4!�54DN C' LIn. © 2 Zip: (includes Durham,King City and a Phone: _0-0- 3/a-S'�90 Fax: . 3—�0 31- 9 S portion of unincorporated Washington 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 nn ,, I:\CURPI.N\Masters\Land Use Applications\Public Patine Description of work: C�4J NiV�Z'� �Jt1,�f e �N Improvementd«x Z4-'Sj J 0A-r2tf f369 'S1IJ Al Estimated value of work(within the public right-of-way): $ 700 Is work related to a LAND-USE DECISION? YES 0 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 1 503-718-2464 1 www.tigard-or.gov Page 1 of 5 APPLICANTS: - - - Ta.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,apptiicant are different people,the applicant must be•the purchaser of record or a lessee in,possession with written authortzationfrom,the owner or,atil agent,of the owner. The,owner(s)must sign this.application in the space provided on,the backiof•this form,or submitwrittewauthorization with,this application (Detailed[Submittall Requirement Information sheets can be;obtained,upon request,for all types of Land'Use Applications.) BY SIGNING BELOW,'THE APPLICANTS)SHALL CERTIFY THAT: e The above request does not violate any deed restrictions that maybe attached'to or imposed-uponthe subject propegy. e 'If the application,is granted,the applicant will exercise the rights granted in accordance,with the terms and subject to all Ithe conditions and li nutations of the approval. e r 6,of•the above,statements,and the statements in the plot plan,.attachments, and!exhibits transmitted herewith, are mie; 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 den}dng;the-application. SIGNATURES'.of eachl owner of the subject,property. DA'Z'E-D this 1Q' clay of '-}�i�Y�1 gC°?� 120 f 3- -XM-C. VUA4 46A !Wa-�Q Applicant/Authorized Agent'sSignature Owner's Signa re Owner's Signature Owner's Signature Cityof Tigard 1 13125 SW 1-Iall1 BlVd.,Tigard,OR'97223 503-718-2464 ji -,vnv\v.tigard'-or;gov I Page 2 of 5 ,SKETCH AREA: aZ � T�- 'q PR O P o s OD NEW P F PaoPas� 2H NE1n1 cATf3A-11 (4 N � V X AAA(Q5, Q , _ �- hw�Sr sT- A\/c 3 � S� Cite of Tigard 13125 SW Hall Blvd.,'figard,OR 97223 503-718-2464 www.tigard-or.gov Page 5 of 5 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 estitnate X 2% Plan Review Part 2: All public water S>'stem improvements Engineer's estimate X 12% Total Permit Fee = Part 1+ Part 2 PFI Permit Fee Exemptions: There will be no permit fee charged,or assurance required for the following types of work: o Sidewalk or driveway repair(less than 20 lineal feet) e Relocate or replace mailbox o Ditch cleaning that does not involve regrading. o Weephole repair o Curb repair or replacement(less than 20 lineal feet) o Lawn sprinkler system installation or repair o Street tree pruning or planting o Planter strip landscape maintenance o Test wells 2. Addressing Fee: Tlie fee for this service is $50.00 per address. SAMPLE, Mihimurim.Sketch.R'equi eirnents 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 J Trees Existing S/W or D/W Apron Existing Utility Locations(sewer,water,storm) Cite of"Tigard 13125 S\\7 Hall Blvd.,"Tigard,OR 97223 1 503-718-2464 1 wwxv.tigard-or.gov I Page 3 of 5 SAMPLE SKETCH: sIV „ �. „ l Edge of Pavement I "Q— Ditch Streetlight ---•—•---•--- —r--- an • ° uArr4dn � � o ' T --mopos cf TimrTi'ne-- 4 � Existing House 1 I �I I Existing>� • Driveway vi I 1 NI g, �� I i o Existing Shop _ a Powerpole I . I I o 1 a 95' I ------- ---------- property Line I I iFire Hydrant(FH) I Scale: 1"=30' I i I 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) Cite of Tigard 1 13125 S\\'Hall Blvd.,"Tigard,0R 97223 1 503-718-2464 1 N%1v`v.tigard-or.gov I Page 4 of S CITY OF TIGARD RECEIPT 0 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 Receipt Number: 193066 - 09/12/2013 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12013-00035 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 010477 DHOWSE 09/12/2013 $300.00 Payor: Raymond A Schwahn Construction Total Payments: $300:00 Balance Due: $0.00 Page 1 of 1