PFI2014-00017 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 I
Request Permit Action 71ZW1/y
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 - www.tigard-or.gov
TO: 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 %City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: !i'1: ( 2-0 1+ - D O O 17
Site Address or Parcel#: 134.61 5`J 1 F-If Z-'11J C1 Lt-J ,
Project Name: 5/0 QPM ?--
Subdivision Name: Lot#:
EXPLANATION: /-rO T L'p AT-Jr 1-0 P-re,oq-12
E4 6M 9-ht_ HA-5 /X G;)� /�J A-e, MO-7- c7F A41 S PL&,"�T
`1�1I S Iv" � � �T Pi�'-(L,r...c i. N O F rL r.5
Signature: kd-� Date: 2/
Print Name: At (k 1L kJ H (T`�
Refund Policy
1. The Community Development Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 801/6 of the land use application fee for issued permits.
d) not more than 80%of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80%of the building permit fee for issued permits prior to any inspection requests.
2 All refunds will be returned to the original payer in the form of a check. Please allow 3-4 weeks for processing refund requests.
• ' OFFICE USE ONLY
Rte to Sys Admin: Date I By Rte t -aI B
Refund Processed: Date A B Invoice Processed: Date B
Permit Canceled: Date B Parcel Tag ridded: Date B
Receipt# Date Method Amount$
I:\Building\Fomes\RegPenT itAction_062614.doc
CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12014-00017
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 06/09/2014
Parcel: 1 S133CD04900
Jurisdiction: Tigard
Site address: 13669 SW FEIRING LN
Subdivision: COTSWALD MEADOWS Lot: 47
Project: Van Dusen/Greathouse
Project Description: Replace one 5 square of sidewalk.
Owner: FEES
Description Date Amount
Pe "01 Fee
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
RYAN VAN DUSEN
13669 SW FEIRING LN
TIGARD, OR 97223
PHONE: 503-719-3648
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.
Permttlicant
Sign Vol
Signature:ure:
Issued By: Au
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
for
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146,
r �6
_ M.Y
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' City of Tigard RECEIVED 05 2014
Public Facility Improvement
CITY OF TIGARD
(PFI) Permit PLANNING/ENGINEERING
General Information: FOR STAFF USE ONLY
Property AdEngineering
1 dress/Location(s): Case No. �l_amu 14 -- obo 1 i
Fee: hU
Receipt No.:
*Applicant's Name: km!-1.J Vt,nJ te:
Address: 1310k.9 S Lj F e i ', T L R N-,P- Application Accepted: t By:
City/State: "n IA- r\ a Zip:`] -1?-2-3
Primary Contact: 3 1 L 9 4. S& REQUIRED SUBMITTAL
INFORMATION
Phone: Fax:
E-Mail: Professional Engineered Plans are required
for:
Contractor's Name: ��S o W A '�nC.�_o_�t. S.�l.y�,"o^,C.n�.-� �'�b�treet Widening
• Subdivision Infrastructure
CCB# [2.0 5; -7 Expiration: 7 (z/rsr • Main utility line extension:
Address: 4y 9b S � �C-t n�►'�a�-► R�...o
0 Storm Drain,Sanitary-Tigard
0 Water-Tigard Water Service Area
City/State: &Nou Com-,o,j Zip:,1a u�- (includes Durham,King City and a
v��3 33 89 2 3 Fax: portion of unincorporated Washington
Phone: County)
`*Note:See Engineered Plan
Plans By: p n C 1110- C-t,,Q AA-J:2_ 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
1:\CCRP1,N\Masten\].and Csc Applications\Public Facaity
IQD
Description of work: L,\ J�: -rAA ., 'S Impnn•ementdocx
Estimated value of work(within the public right-of-way): $
Is work related to a LAND-USE DECISION? YES ❑ NO 0
If so,please specify (MLP, SDR, SUB,etc.) case #:
Is the work related to a BUILDING PERMIT? YES F� NO
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 be attached to or imposed upon the subject property..
♦ If the application is granted,the applicant will exercise the rights granted in accordance xvith 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 anv 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 �Une� 120
Applicant/Authorized Agent's Signature Owner's Signature
.1/1 e�z:�
Owner's Signature Owner's Signature
Citi-of Tigard 1 13125 Sit'Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 Nv«%v.tigard-or.gov I Page 2 of 5
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 196384 - 06/09/2014
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12014-00019 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
Fund Transfer DHOWSE 06/09/2014 $300.00
Payor:
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
T�.�!✓.Src�'L. �2 Ci�
Receipt Number: 196383 - 06/09/2014
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
P F 12014-00017 $-300.00
Tota I: $-300.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Fund Transfer DHOWSE 06/09/2014 $-300.00
Payor:
Total Payments: $-300.00
Balance Due: $0.00
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
0121
Receipt Number: 196353 - 06/05/2014
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12014-00017 PFI Permit Fee 100-0000-43114 $300.00
Tota I: $300.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 2716 AKOWACZ 06/05/2014 $300.00
Payor: Rose Wong
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
" Request Permit Action RECEIVED
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
TO: CITY OF TIGARD CITY OF TIGARD
Building Division Services Supervisor BUILDING DIVISION
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUE (attach case fee schedule and provide ex lanation below).
❑ REMOVE/REPLACE CONTRACCTO^�,„ PERMI —7 cancel per .
Permit #: p/ o(J ��' 0ec l / ��Q/I
Site Address or Parcel #:
Project Name:
Subdivision Name: G Lot #:
EXPLANATION: L"i �r p�e ONO/I (4,,eot,
h yAk e"(
Ir A
Signature: Date:
Print Name: sir(
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80%of the land use application fee for issued permits.
d) not more than 80%of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80%of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2-4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date By Rte to Admin: Datc / B
�5 Processed: Date / By Invoice Processed: Date B
Permit Canceled: Date B Parcel Tag Added: Date B
Receipt# Date Method Amount$
I:\Building\Forms\RegPermitAction.doc Rev 05/25/2012
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 196353 - 06/05/2014
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12014-00017 PFI Permit Fee 100-000043114 $300.00
Total: $300.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 2716 AKOWACZ 06/05/2014 $300.00
Payor: Rose Wong
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
CITY OF TIGARD RECEIPT
S 13125 SW Hall Blvd..Tigard OR 97223
503.639.4171
Receipt Number: 196383 - 06/09/2014
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
P F 12014-00017 $-300.00
Total: $-300.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Fund Transfer DHOWSE 06/09/2014 $-300.00
Payor:
Total Payments: $-300.00
Balance Due: $0.00
Page 1 of 1
CITY OF TIGARD RECEIPT
_ 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 196384 - 06/09/2014
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12014-00019 PFI Permit Fee 100-0000-43114 $300.00
Tota I: $300.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Fund Transfer DHOWSE 06/09/2014 $300.00
Payor:
Total Payments: $300.00
Balance Due: $0.00
Community Development
Accela Cashier Transaction
Finance Department Route Slip
Date: (� f
To: y Linda Compton
Liz Lutz
From: Dianna Howse /
Re: Receipt#(s): /y� 3�3� i963;C3 / dr-
The following cashier transaction has been processed
and included in the Accela Revenue Account Report:
Check Refund (already deducted in
Springbrook by Finance when check was cut)
Credit Card Refund
Reversal:
Other:
1- 1Zx/7 C.-JE /0EM4V iT' 7-Z
A-iyo 77/--c72 ,
Thank you!
I:\Budding\Fo ens\RteS lip-Financ eRe q-0507 13.doc
Page 1 of 1