PFI2013-00045 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12013-00045
13125 SW Hall Blvd., Tigard OR 97223 503.718.2421 Date Issued: 11/26/2013
Parcel: 1 S134BD07005
Jurisdiction: Tigard
Site address: 11350 SW COTTONWOOD LN
Subdivision: ENGLEWOOD NO.3 Lot: 230
Project: Speaks
Project Description: Replace driveway approach to repair crack in existing and expand from 24'to 29.5'.
Owner: FEES
Description Date Amount
PHONE: PFI Permit Fee 11/26/2013 $300.00
Contractor:
PHONE:
FAX:
Applicant:
BRETT WEINEL
8950 SW LOCUST ST.
TIGARD, OR 97223
PHONE: 503-977-5080
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:
• L
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
MrsCity of Tigard
Public Facility Improvement
(PFI) Permit
General Information: ^ FOR STAFF USE ONLY
Property Address/Location(s): �W Cr)&A 0D{� Engineering
CaseNo.: PF1201 —000
Fee. 1�`11 '
Receipt No.: I q 01
*Applicant's Name: C��� Date: l 26 I
Address:gC14,S0 s ciJ �L L. Sr Application Accepted: ZD By:
/�
City/State: / „f� ,�•j Vr Zip:
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Primary Contact: f REQUIRED v'� / Fax:_ Add SUBMITTAL
��� , // INFORMATION
Phone:Ce/� �r ����
E-Mail:_ (��Y �. Professional Engineered Plans are required
for:
• Street Widening
Contractor's Name: • Subdivision Infrastructure
CCB# �� Expiration: /O_0_/V • Main utility line extension:
Address: 0 Storm Drain,Sanitary—Tigard
0 Water—Tigard Water Service Area
City/State: Zip: (includes Durham,King City and a
portion of unincorporated Washington
Phone: Fax: 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:6/18/2013
l:mnro��cmcntdocx\CCRPI.N\Masters\Land Use Applications\Public Facility
I
Description of work: 61C /Y✓r_4j6LN,/
Estimated value of work(within the public right-of-way): $ 2Z,dC), 60
Is work related to a LAND-USE DECISION? YES F—] NO 0'
If so, please specify (MLP, SDR, SUB,etc.) case #:
Is the work related to a BUILDING PERMIT? YES F-1 NO Efr
If so, please specify (BUILDING PERMIT) case #:
City of Tigard 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 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
(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 attached to or imposed upon the subject propeny.
♦ 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 // 2 2—(�2 '� —day of ,209
Applicant/Authorized Agent's Signature Owner's Signature
____) 46,4�qlj �,
AOwne Signature Owner's Signature
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 2 of 5
SKETCH AREA:
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Ilse ID
City of Tigard 13125 S\X'Hall Blvd.,Tigard,OR 97223 503-718-2464 www.tigard-or.gov Page 5 of 5