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
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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
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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