ROW2014-00016 City of Tigard •• COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 0
111 3/zs-r
Request Permit Action
T1G n P 1 ' 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
'1'O: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor OCity Staff
(check unr'
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
El CANCEL/VOID PERMIT APPLICATION.
n REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
(� REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: t`)A v 9-0 1y-(JWW i .Q
Site Address or Parcel #: ,S CO/ Z
Project Name: IJ'i\l Nmimot
Subdivision Name: Lot#:
EXPLANATION: Permit- w e nErt 1nCl . M) ,fe?c Wei
Ct klearri
Signature: Date: MS I
Print Name: f-OWlC 2-
$&Awed Policy I
I. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80°o of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80°o of the land use application fee for issued permits.
d) not more than 80°n of the building plan review fee when an application is canceled before any plan review effort has been expended.
c) not more than 80°o of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in tht same n, rh id in which payment was received. Please allow 2-4 weeks for processing refunds.
FOROFFICL 1.1
Rte to Sys Admin: Date h, Rte to Iitig Admin: Date_g/2$//y By 4►t
Refund Processed: Date �i 7 •�By Invoice Processed: Date 13�
Permit Canceled: Date 3 2.0y _i!"' Parcel Tag.lddcel: Date By
Receipt# Date Method Amount$
I:\Building\Dorms\RegPermir.Action.doc Rev 05/25/2412
RECEIVED
City of Tigard FEB 1 2 2014
N Application for Work in the Right-Of--Way CITY OF TIGARD
•TIGARD ROW Permit PLANNING/ENGINEERING- - -
Property Address/Location(s):10586 SW Windsor PI $32 4422-- FOR STAFF USE ONLY
WR#3405126 ����'"`��
Right-of-Way
Case No.: :10 0 I X OI •
*Applicant's Name:NW Natural Z �� B
Application Accepted: y: kr-
Address:220 NW 2nd Av
Portland OR 97209 Application Reviewed: H By: G1
City/State: Zip:
$300.00 Application Fee Due: Yes❑ No❑
Primary Contact:Judy Doblie
503-226-4211 X4428 503-273-4822 Applicant Notified: 15.1 IA
Phone: Fax:_
Email:nwnpermits @nwnatural.com Receipt No.:
REQUIRED SUBMITTAL
Contractor's Name:Same INFORMATION
CCB# Expiration: • Application form,completed and signed
Address: • Submit one (1)copy of scaled sketch of
City/State: "Lip: the proposed work to be done
Phone: Fax:
• Submit one (1)copy of traffic control
plan
Email:
Professional Engineered Plans are required
Plans By: for:
Address: • Street Widening
City/State: Zip: • Subdivision Infrastructure
Phone: Fax:
• Main utility line extension
Email: I:cutpin\rummers\land use applscnnons\row app.docs I Rev.7/19/12
Description of work:Relocate service from being bored through storm drain. Main on the 5 in ROW. Possible street cut.
/ •��_ �i. • 44.)' '/i_f+ - /AL-. •_ . t 4•-‘4
Estimated value of work(within the public right-of-way): $
Is work related to a LAND-USE DECISION? YES 0 NO 111
If so, please specify(MLP,SDR,SUB,etc.)case#:
Is the work related to a BUILDING PERMIT? YES ® NO 0
If so, please specify(BUILDING PERMIT)case#:
Date:2/12/2014
Signature of Applicant/Permittee: °°•°°•°°°°°
Print Name:Judy Doblie Title:Engineering Coordinator
City of Tigard I 13125 SW Hall Blvd.,Tigard,OR 97223 I 503-718-2464 I www.tigard-or.gov
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NW Natural PLAT: 1-041-018 COUNTY: WASHINGTON !� 02112!14 13:38
(503)226-4211 i TOWNSHIP: T01S RANGE: R01 W SECTION: 34NE SCALE: 1 IN = 100 FT !�J USER ID:jkd