PFI2014-00021 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PFI2014-00021
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 06/09/2014
Parcel: 1 S133CD05100
Jurisdiction: Tigard
Site address: 13617 SW FEIRING LN
Subdivision: COTSWALD MEADOWS Lot: 49
Project: Yeung Sidewalk Repair
Project Description: Sidewalk repair at 13617 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:
MARIA YEUNG
42-70 147TH STREET
FLLUSHING, NY 11355
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.
Permittee/ApplicantAto�
Signature:
Issued By: "_
loor
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
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City of Tigard
Public Facility Improvement SUN 0 5 214
(PFI) Permit G\V OF�G JEERING
P►ANN�NG�EN
General Information: FOR STAFF USE ONLY
Property Address/Location(s): �Q,y>�j Engineerin
Case No.: TE12ol 4—00021
0 '7 Fee:
Receipt No.:
*Applicant's Name: \ Date: (0T1�1
Address: �" Application Accepted:0&1_4 By.AK_
Cit-,•/State: "Lip: ((
1'rimar, ntact: REQUIRED SUBMITTAL
INFORMATION
Phone: 5-03 Wo 3 Zu Fax:
l Mail: Professional Engineered Plans are required
f
n
Contractor's Name: � • Street vWidening
ubdiision
Infrastructure
CCB# 1503 Expiration: • Main utility line extension:
Address:
rl Ua Al CIA
0 Storm Drain,Sanitary—Tigard
0 Water—Tigard Water Service.Area
City/State: V Zip: 9106 (includes Durham,Bing City and a
Phone: (�V3) 3/30
(�"I Z 7?Fax: portion of unincorporated Washington
County)
C "*Note:See Engineered Plan
Plans By: .�1' e— Submittal Checklist attached.
Address: For all other work:Submit scaled sketch of the
City/State: Zip: work to be done. (see attached minimum sketch
requirements and provided sketch area).
Phone: Fax:
Lpdawd:6/24/22013
1:'CL'RI'1.N\�tastcrs\land U,. Applications\Public hacdvc
e Impsccmentdx�
Description of work: 51- la-Ek if-bai V
Estimated value of work(within the public right-of-way): $
Is work related to a LAND-USE DECISION? YES ❑ NO 2
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 #:
Citi'of Tigard 1 13125 SXR'Hall Blvd.,Tigard,OR 977223 1 703-718-2464 w-ww.tigard-or.gov Page 1 of S
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
(Detailcd Submittal Requirement Information sheets can be obtained,up(>n request,for all tapes 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 propert}_
♦ 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 day of ,20
Applicant/Authorized Agent's Signature Owner's Signature
Y11Ap-IA 7U
` Owner's Signature F Owner's Sipmeam N AjM E
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 www.tigard-or.gov I Page 2 of 5
—wnen toe owner aha toe applicant are anterent people,the appucant must oc the purchaser of recora or a lessee to possession wrtn
written authorization from the owner or an agent of the owner. The o lier(s)must sign this application in the space provided on the
back of this form or submit a written authorization With this application
(Detailed Sulxnitrtl Re•ywronc•nr Infornunon sheets can be obnuned,upon request,forall r.pcs of land I'se.Applications.;
BY SIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT:
• The above request does not violate ani•deed rest-„cnons that may be attached to or imposed upon the subiect Pr R=-
• If the application is granred,the apphc:utr kill exercise the rights yrantcd to accordance with the icnins and sul>vcl to all the condition.
and linutatiuns of the approval.
♦
All of the above statcmcnrs and flit: in the plot plan, attachment%. and cxhibir: transnurted herewith, are tnu•: unci the
applicants so acknou'Icdgt that any pernur issued,hascd on this application,mac be revoked if it is found that an% such statetncnrs arc
false.
♦ 'Me applicant has read the entin•contents of flit application,including;the policies and criteria,and understands clic rc•cluirt:ntent:� for
approxing or denying the application.
SIGNATURES ofsArh owner of the subject pmperr.
1).1•i FD 1111% dac of
Applicant/Authorized Agent's Signature Owner's Signature
Owner's Signature C'PlN Owner's Sim ate• NAME
lain cif Tigard 1 13121 ti1C'1 611 Blvd..Tigard.()R 97223 1 i(13--18-2464 Page 2 of 5