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PFI2014-00020 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12014-00020 e 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 06/09/2014 Parcel: 1 S133CD05400 Jurisdiction: Tigard Site address: 13570 SW FEIRING LN Subdivision: COTSWALD MEADOWS Lot: 52 Project: Wong Sidewalk Repair Project Description: Sidewalk repair located at 13570 SW Feiring Lane. Owner: FEES Description Date Amount PHONE: Contractor: ABSOLUTE CONCRETE AND SOLUTIONS 44900 SE COALMAN ROAD SANDY,OR 97055 PHONE: 503-330-8923 FAX: Applicant: STEVEN WONG 13570 SW FEIRING LANE TIGARD,OR 97223 PHONE: 503-890-3320 Total $0.00 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. Perm ittee/Applicant Signature: 1 Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY } c: T' City of Tigard J0IV 05 2014 ■ Public Facility Improvement P,.,ctiN �'_r fHAD (PFI) Permit "'�G,N11AING General Information: 1359 s� FOR STAFF USE ONLY 7 Property Address/"cation(s): 1 15 n 1 0 Im"MA I A& II Engineering Case No.: ?FI201q-'9P0W u' Fee Receipt No.: *Applicant's Name: ST�c/�n► �o�� Date: (00151 j Y Address: 1351b)S k �M 91a G LA K Application Accepted:1015By:AY 2-2-3 - City/State: (1 Q Zip: � -7 � Primary Contact: REQUIRED SUBMITTAL Phone: 3 — 3 3 Z4 Fax: INFORMATION E-Mail: is-,Ib Professional Engineered Plans are required G� W for: Contractor's Name: ame: n > • Street Widening YYT gs • Subdivision Infr astructure CCB# 12-D15n3 Expiration: • Main utility line extension: 0 Storm Drain,Sanitary-Tigard Address: SE ri"m - 0 Water-Tigard Water Service Area City/State -7v/D 6 t5 (includes Durham,King City and a portion of unincorporated Washington Phone: �3 3 3 �' 2 Fax: County) ( . j t **Note:See Engineered Plan Plans By: h5b ��t rM C Submittal Checklist attached. Address: Ca AM-12— 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 y1 p, 1:\CURPLN\Masten\I and Use Applications\Public Pacilit Description of work: 1 (Y� 1(d C�� i4a 1 I Impn""en'"'t•d«x Estimated value of work(within the public right-of-way): $ Is work related to a LAND-USE DECISION? YES F-] NO If so,please specify (MLP, SDR,SUB,etc.) case#: Is the work related to a BUILDING PERMIT? YES F-] NOF 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 I Page 1 of 5 r 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 t)pes of Land L'se 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 SACh owner of the subject property. DATED this day of ,20—LLJL— Applicant/Authorized Agent's Signature Owner's Signature ees Signat, Owner's Signature City of Tigard 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 2 of 5