PFI2014-00076 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12014-00076
t 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 09/18/2014
Parcel: 1 S 134AB00200
Jurisdiction: Tigard
Site address: 11302 SW IRONWOOD LP
Subdivision: ENGLEWOOD Lot: 1
Project: Bonner Sidewalk replacment
Project Description: Replace existing sidewalk located at 11302 SW Ironwood Loop.
Owner: FEES
Description Date Amount
PFI Permit Fee 09/18/2014 $300.00
PHONE:
Contractor:
CINDY'S CONCRETE, LLC
PO BOX 1254
OREGON CITY, OR1 97045
PHONE: 503-650-2688
FAX:
Applicant:
THOMAS RYAN
11302 SW IRONWOOD LOOP
TIGARD, OR 97223
PHONE: 541-390-4441
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
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 197649 - 09118/2014
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12014-00076 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
Credit Card 061230 TLEHRBACH 09/18/2014 $300.00
Payor: Thomas S Ryan
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
City of Tigard
Public Facility Improvement
(PFI) Permit
General Information: FOR STAFF USE ONLY
Property Address/Location(s)://3 d 2 .51A " 16A&06n 1—P Engineering
Case No.: ?Fi X14`ccy7w
J'4�r , DR 97zz�
Fee•4300,00
Receipt No
*Applicant's Name: ACA.-C X- Iz4AAJ Date: I M1 14
Address: 1130-2- Application Accepted S 7. By:�
Citi•/State:� rf�Q � �/� ip: 97 Z23
Primary Contact: REQUIRED SUBMITTAL
Phone:.3"yl-34d• Fax: INFORMATION
E-Mail: iv Professional Engineered Plans are required
for:
/� // • Street Widening
Contractor's Name: . Subdivision Infrastructure
CCB# !2,2, O Expiration: Z O • Juin utility-line extension:
0 Storm Drain,Sanitary-Tigard
Address: ��� � /?-.5� _ 0 Water-Tigard Water Service Area
City/State: // Zip: 7oYaS (includes Durham,King City and a
Phonc&5_93- t3.7� Z �� Fax:S�3 � )�.f(tZ�Q portion of unincorporated Washington
County)
"Note:See Engineered Plan
Plans By: Submittal Checklist attached.
Address: For all other work:Submit scaled sketch of the
City/State: "Lip: work to be done.(see attached minimum sketch
Phone: Fax:
requirements and provided sketch area).
Updated 6V24/2013
L\CL'RPLN\Masten\land Usc ApplicatumsWublic Fadity-
Description of work: &APY-L- "E jeAt e— P,!;- Improccmem.dncs
cJa oQ r• `� o� / o f Z'� �� !,�
Estimated value of work(within the public right-of-way): $
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 SXX'Hall Blvd.,Tigard,OR 97223 503-718-2464 ww-w.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
(Detailed Submittal Requirement Information sheets can 1)c obtained,upon request,for all t}pes of Land Use Applications.)
BY SIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT:
♦ The above request does not violate an deed restrictions that may 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 / S� day of /—, Q ✓ 20 �
I
5.
Applicant/Authorized Agent's ature Owner's Signature
Owner's Signature Owner's Signature
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 2 of 5
M1
DEVELOPMENT ENGINEERING FEES
1. Public Facility Improvement(PFI)Permit:
Part 1: All non-water system improvements
Engineer's estimate X 5% (less$300.00 submittal fee)
Engineer's estimate X 2%Plan Review
Part 2: All public water system improvements
Engineer's estimate X 12%
Total Permit Fee= Part 1 + Part 2
PFI Permit Fee Exemptions:
There will be no permit fee charged,or assurance required for the following types of work:
• Sidewalk or driveway repair(less than 20 lineal feet)
• Relocate or replace mailbox
• Ditch cleaning that does not involve regrading.
• Weephole repair
• Curb repair,or replacement(less than 20 lineal feet)
• Lawn sprinkler system installation or repair
• Street tree pruning or planting
• Planter strip landscape maintenance
• Test wells
2. Addressing Fee: The fee for this service is $50.00 per address.
SAMPLE
Minimum Sketch Requirements
North Arrow Property Lines&Dimension Slope of Property
Street&Street Name(s) Existing Building,Structures Utility& Street Light Poles
Proposed Work Existing Curb or Edge of Pavement Trees
Existing S/W or D/W Apron Existing Utility Locations (sewer,water,storm)
Cityof Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 3 of S
SAMPLE SKETCH:
Edge of Pavement
I -0— Ditch
Streetlight I — —•—•---•—•— —r—
r '—
fr� Rain Draat
r I
� o
I I .
' T–�iopos d�5elw'e�Tine"
Existing House
I Existing i
�. I ,s Driveway
3is I
a
o
a
v�
d � �
of 1
Existing Shop i
J I
Powerpole I
I I a 95' 1
I O property Lme
-------
Fire Hydra t
-FirHydrant(FH)
I � I
Scale: 1"=30'
I I
I I I
I I
� � I
Minimum Sketch Requirements(Put"n/a"if Not Applicable):
North Arrow Property Lines&Dimension Slope of Property
Street&Street Name(s) Existing Building,Structures Utility&Street Light Poles
Proposed Work Existing Curb or Edge of Pavement Trees
Existing S/W or D/W Apron Existing Utility Locations(sewer,water,storm)
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 4 of S
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SKETCH AREA:
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City of Tigard 13125 SW Hall Blvd.,Tigard,OR 97223 503-718-2464 www.dprd-or.gov Page 5 0j 5