PFI2014-00018 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12014-00018
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 06/09/2014
Parcel: 1 S133CD05000
Jurisdiction: Tigard
Site address: 13645 SW Feiring LN
Subdivision: COTSWALD MEADOWS Lot: 48
Project: Warner
Project Description: Replace sidewalk across entire propery frontage, replace driveway apron, relocate mailbox because it is
near storm drain and possibly raise storm drain to match weephole location.
Owner: FEES
HAROLD&BETTE WARNER Description Date Amount
13645 SW FEIRING LANE PFI Permit Fee 06/05/2014 $300.00
TIGARD, OR 97223
PHONE: 503-524-5710
Contractor:
PHONE:
FAX:
Applicant:
PHONE:
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.
Permittee/Applicant
Signature:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
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RECEIVED
City Of Tigard JUN 05 2014
Public Facility Improvement
CITY OF TIGARD
(PFI) Permit PLANNING/ENGINEERING
General Information: FOR STAFF USE ONLY
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Property Address/Location(s): EngineeringCase No.: P�'� A ly
S.W . Fee: 5,300
DcAV o,J 41?2 2 3_Q 1 �a Receipt No.: cj(o 3q I°
*Applicant's Name: Wllkko L-0 A R��� Date: co - !5 - 1 q
Address: Application Accepted: r By:�
Mr. & Mrs. arner
Cite/State: 13rA5 Sw Fairing Lane Zip:
Tigard, OR 91223-1607 �� L REQUIRED SUBMITTAL
Primary Contact: ,l INFORMATION
!S_02
Phone: �3 S T S �'l V Fax:
/ Professional Engineered PLns are required
E-Mail: 14 A+2 VJ,�2 [J F2 � �ii o n 4-i C_ fm.
nn I r �, . Street Widening4 L
Contractor's Name: . S„LS 4£ -”"tea �����U�S C • Subdivision Infrastructure
CCB# 12 0.5 Expiration: -1 \\ ISS _ • Main utility fine extension:
0 Storm Drain,Sanitary-Tigard
Address: /V X10 O S Ce�L rrnlv.j Q 0 \eater-Tigard Water Service.Area
City/State: �'� ^f Zi !�U SS— (includes Durham,Icing City and a
- �� p portion of unincorporated Washington
Phone: �-5 d3 33 o--26'k Z 3 Fax: Count)')
"Note:See Engineered Plan
f
Plans By: i'Yl � 2 L 92- -G>-4 ane6, Submittal Checklist attached.
Address: For allother work:Subrnit scaled sketch of the
City/State: Zip: work to be done. (see attached minimum sketch
requirements and provided sketch area).
Phone: Fax:
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f�Ji}V i �rorc cn docs
Description of work: �l P P,�ta�
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Estimated value of work(within the public right-of-way): $
Is work related to a LAND-USE DECISION? YES D NO-F7
If so,please specify (MLP,SDR,SUB,etc.)case#: 7"
Is the work related to a BUILDING PERMIT? YES F� NO
If so,please specify (BUILDING PERMIT) case#:
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 www.tigard-or.gov Page 1 of 5
APPLICANTS:
To consider an application complete,you will need to submit ALL of the REzUIRED 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 maybe attached to or impgsed upon the subiect,pronerty.
♦ 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 tet— day of -�T V�� ,201
IL
Applicant/Authorized Agent's Signature er's Sign re
Owner's Signature Owner's Signature
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 www.tigard-or.gov I Page 2 of 5
CITY OF TIGARD RECEIPT
= 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 196346 - 06/05/2014
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12014-00018 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
Check 876 CCAINES 06/05/2014 $300.00
Payor: Warner Rev Living Trust
Total Payments: $300.00
Balance Due: $0.00
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