PFI2015-00010 T44
City of Tigard
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PUBLIC WORKS — ENGINEERING
Public Facility Improvement (PFI) Permit
TIGARD
DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL
Check one: ❑ Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS
Ge- ` /� ❑ Minor work in right-of-way
Detailed description: ��c,� � [JL5� to �-6
(sidewalk repair,curb cut,street
7 j (.L2t.CZ�� if f_ ��r��...._ opening,etc.)inquires:
•Application form,completed
J r' l/ 7 Q �) J and signed
•Submit one(1)copy of scaled sketch
Property address/location(s): fT/ „ n �� 6t f c.rti b i l&t� of the proposed work to be done
�f •Submit one(1)copy of traffic
control plan
-OR-
/J i Li✓S,s ❑ Substantial project avrk requires
Applicant's name:
// above items and professional
Address: 300 C 1 t-t r-L,LA engineered plans for.
y •Street widening
City/state: Zip: �7 1 1 ! •Subdivision infrastructure
Phone:
- v���,��� t-( •Main utility line extension:
- mail: �1� _�
- Storm Drain,Sanitary—Tigard
/ - Water—Tigard Water Service
Contractor's name: &711 ��CC.0 J/..�. IILl._ Area(includes Durham,King City
CCB#: 1 JC 1i 41!j Expiration: J i2.� and a portion of unincorporated
Washington County)
Address: 1�„`7 P
City/state: -�Lb 11A, �w.vt,1l,6 Zip:1e_ CLr-► DEIJVEC APPLICATION TO:
City of Tigard
Phone: �;rJ3-!131-„ C40 Email: Planning/Engineering
13125 SW Hall Blvd.
Engineer's name: Tigard,OR 97223
Applications for"minor work in right-of--way”
Address: only may be emarlM to:
City/state: Zip: r°wmer'r'itsQard-or-eov
Phone: Email:
, Case No.: RFT_ do(6-bpd
Estimated value of work (within the public right-of-way): $ ` d/ 3(370'66
Application submittal fee:
Is work related to a LAND-USE DECISION? ❑ Yes p/No Application accepted:
If so, please specify gAL.P, SDR,SUB,etc.) case #: By:— Date: k/ 2,1 1
Application Is work related to a BUILDING PERMIT? LSI Yes ❑ No
plication reviewed:
By: Date:
If so,please specify(BUILDING PERMIT)case#: FBuRaC14--Qq�j
Applicant notified:
By: Date:
1.\0JMW#VAM%WMVMW uw eppgranmr RM.071V4 4
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-ongov • 503-718-2421 • Page 1 of 4
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APPLICANTS
NOTE: Person specified as"Applicant'shall be designated"Permittee"and shall provide financial assurance for work.
*Wlien 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 die owner. T1ie owner(s)must sign this application in the space provided or submit a written
authorization with this application.
BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT:
• The above request does not violate ny deed restrictions that may be attached to or imposed tenon the subject propc
• 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 required.
Applicant/Authorized Agent's signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
Owners signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.6gard-or.gov • 503-718-2421 • Page 2 of 4
11380 SW Greenberg idol, T i parol
Lsga l : 15135CA TL. #01200
125,52'
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EXTEND • TIE CUTTER
/ DRAINS INTO HOUSE 8' W 5' FENCE
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Sits Man
Scall: 1" = 30,
FEB-17-2015 06:56 From:LASSLETT EXC 5038570005 To:5035981960 P.3/3
City of Tigard • COMMUNITY DEVELOPMENT DnuARTMnNrEB 7
• Request for Permit Action (!T2V t p
13125 SW liall Blvd, s Tip,rd,Oregon 97223 • 503-718 2439 Ntf
TO: CITY OF TIGARD V
Building Division .2 bJJ
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Jinx: 503-598-1960 'rignrdBuildingl'crmitslct tignrd-or,gov
FROM: ❑ Owner ❑ Applicant [� Contractor ❑ City Staff
Check(✓)menu
REFUND OR Name:
INVOICE TO. (11Udn1Cly O[If1411JrtILWI) C woo 0
�\• L Mailing Address:
City/State/Zip:
Phone No.: S ql —
p PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCF?L/VOT0 PERMIT APPT.ICATTON.
REFLJN1-)PEMMT7' l-.B S (attach copy of original receipt and provide explanation below).
[] INVOJCE FOR Fh:ES DUI:"s (attach case fee schedule and provide explanation below).
❑ REMOVr/RI;PL.ACI CONT11ACTOR ON P:ERMTT(do not cancel permit).
Permit#:
Site Address or Parcel#:
Project.Name;
Subdivision Name: Lot#.
EXPLANATION: �µ
Signature: Date: i15�
Print Name: '
tlr m I j'011cv
T The city,s community i3cvelopment Dirmlor,nuilding Official or City engineer may autlhnrixc the rcfund of
• Any fee which was erroneously paid or collected
• Nnt more than Ho%of the appliearion nr plan review fee when an application is wiehdmwn or rxmculcd befntc rcvieuv effort
has bean expended,
s Not more than H(r/o of the applic itinn or permit fee for issued permits prior to any inrpertinn requests. A45-FUW6 >
2 All refunds will be retuneed to the nriOnal payer in the form of a check via US postal service
3, l'lcasu allow 3-4 wccks for prnecssing refund requests.
Route to S s Admin: Date /h13
]3 Route to Recordn: Dare lj
Refund Proceesecl: Date a!v li 1nYO1CC PcOCL'9ECCI: Utile
Pcrmik Canccled; Date S 11 Parcel Ti Added: Dale E]3 ��
I:\jiuilding\L+orals\Ii�lhcrinilrlcti�m�l F&M .TIG
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City of Tigard
February 26, 2015
C Woodruff Construction
Attn: William
PO Bos 909
Grants Pass, OR 97528
Re: Permit No. PFI2015-00010
Dear Applicant:
The City of Tigard has canceled the above referenced permits) and encloses a refund for the
following:
Site Address: 11380 SW Greenburg Rd
Project Name: Columbia Care Services
Job No.: N/A
Refund Method: ® Check#216551 in the amount of$240.00.
❑ Credit card"return" receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account "deposit" receipt in the amount of$
Comment(s): Per applicant's request as permit was not required after change in design.
Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
4�
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 0 www.tigard-or.gov
City of Tigard
Accela Refund Request
This form is used for refund requests of land use,development engineering and building permit
application fees. Receipts, documentation and the RequestforPermit Adian form (if applicable)must
be attached to this request form. Refund requests are due to Accela System Administrator by
each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: C Woodruff Construction DATE: 2/19/2015
Attn: William
PO Bos 909 REQUESTED BY: Dianna Howse
Grants Pass, OR 97528
TRANSACTION INFORMATION:
Receipt#: 199152 Case#: PFI2015-00010
Date: 1/27/2015 Address/Parcel: 11380 SW Greenburg Rd
Pay Method: Check Project Name: Columbia Care Services
EXPLANATION: Per applicant's request as permit was not required after change in design. Refund 80%
of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
F—xam ple: Building Permit Fee Example: 2300000-43104 Amount
PFI Permit Fee 100-0000-43114 $240.00
TOTAL REFUND: $240.00
APPROVALS: SIGN E DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager
If under$23,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY.
Case Refund Processed: Date: oZ By:
I:\Building\Refunds\RefundRequest.doc X 09/01/3010
FEB-17-2015 06:55 From:LASSLETT EXC 5038570005 To:5035981960 P.1'3
P 0 Boz 1279
McMinnville,Oregon 97128
OWA(503)472.7298 Lasslett Excavating
Cell(503)437-2040
Fox(503)714.4056
P"
To: City of Tigard-Building Division Fresno Bill Lesslett
Fax: 503.598-1980 Pegs: 3
Phone: 503-7182439 Oats: 2/17/2015
RE; Request For permit action CCI
0 Urgent 0 For Review CI Please Comment 0 Please Reply 0 Please Recycle
e Comment.
Dear Sirs:
Please refund money paid for this permit as we were able to resolve Rain drain out fall problem with
a less difficult method then tapping a Greenburg Rd catch basin. Please review my request for
Permit action and contact me If you have any questions.
Thank You.
Bill Lasslett
FEB-17-2015 06:55 From:LASSLETT EXC 5038570005 To:5035981960 P.2/3
feb, 2. 02Q15 9:22AM CLIFF 'NOU RUF= CCKSTRUCTICN V0, 93,1 P, 1
CITY OF TIGARD RECEIPT
17126 SW Hall Blvd„'nperd OR 87223
503.638,<171
Recolpt Number: 199162 - 01/27/2016
FEE DENCRIUM Rl-:VEUU§ACCOUNT NUMBER ULD
PF12016-MO10 PR PermltFee 10D-Woo-43114 $30000
Taml: S9D0.00
AAl`M&KLMf,r'li�o gUICK A CC AU.T_H,CODE AQCT ID CASHI R!+MPT DACE 8F CIPt AMT
Check 3927 CCAINES 01x1712016 $300,00
Payor. C Woodruff Conslwbn,LLC
7atal Payments: $30000
Dslorce Dur soon
y
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