PFI2014-00053 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
s COMMUNITY DEVELOPMENT Permit#: PF12014-00053
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 08/13/2014Parcel: 1S135AC05100
Jurisdiction: Tigard
Site address: 10950 SW 95TH AVE
Subdivision: 1993-040 PARTITION PLAT Lot: 2
Project: Winsor Properties Drain
Project Description: Installation of private rain drain system to catch basin at 10950 SW 95th Avenue.
Owner: FEES
Description Date Amount
PHONE:
Contractor:
STRAUSS EXCAVATING
3671 SW 229TH AVE
BEAVERTON, OR 97007
PHONE: 503-649-8117
FAX:
Applicant:
BOB STRAUSS
3671 SW 229TH AVE
BEAVERTON, OR 97007
PHONE: 503-649-8117
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/Applicant
Signature: 7
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
City of Tigard RECEIVED
11 Public Facility Improvement
(PIFI Permit AUG 13 2014
CITY OF TIGARD
Pis" _
General Information: FOR STAFF USE ONLY
Property Address/Location(s): JQ50 ,5..uj_ q.9� \11f, Engineering
Case No.: PF 2-00—OCC)C,2
Fee:
ReceiptNo.: N
*Applicant's Name: �sauS�S` .LL�1�, . L� Date: Oil I 'L4
Address: 36,711 `5 .� ZZg �vr �J Application Accepted:011-5(14 By: AV-
City/State: 'Zip: CV160
Primary Contact:
REQUIRED SUBMITTAL
INFORMATION
Phone:�13. 1�-L4'M Fax:�l3• (o�g-k(17
E-Mail: Professional Engineered Plans are required
for:
Contractor's Name: • Street Widening
���lZ�,�cs L7�XCc�,�w�tr•, �i�nt
• Subdivision Infrastructure
CCB# Expiration:12--It- ly • Main utility line extension:
Addressl(o-1 i S,a.61 22-5 1; ALhe 0 Storm Drain,Sanitary—Tigard
0 Water—Tigard Water Service Area
City/State&,IrSAOV Zip: I in (includes Durham,Kung City and a
portion of unincorporated Washington
Phone: Sb3- (,65 &1Q Fax: S33- 6441-1111 County)
`Note:See Engineered Plan
Plans By: 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
L\CURPI-N\Rlasten\J- d Use Applications\Public I acilitc
Impm�ement.d<x�
Description ofwork:_5, ��at:.,_, r,� zr >r� Z e�fatom,
V„6 td rr,tQ"CA&
Estimated value of work(within the public right-of-way): $ (w,ou
Is work related to a LAND-USE DECISION? YES NO
If so,please specify (MLP, SDR, SUB, etc.) case #:
Is the work related to a BUILDING PERMIT? YES NO
If so,please specify (BUILDING PERMIT) case#:
City of Tigard 1 13125 S\X'Hall Blvd.,Tigard,OR 97223 503-718-2464 1 www.tigard-or.gov I Page I 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 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 L3 day of ��V�� 20
Ali If
Applicant/ uthorized Agent's Signature Owner's Signature
Owner's Signature Owner's Signature
City of Tigard 1 13125 S% 'Hall Blvd.,Tigard, OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 2 of 5
SKETCH AREA:
41
7
3 ?
Cite of Tigard 13125 S\X,'Hall Blvd.,Tigard,OR 97223 503-718-2464 www.tigard-or.gov Page 5 of 5