PFI2016-00086 M
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0
Request for Permit Action
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPerrnits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor Ocity Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL OID PERMIT APPLICATION.
D PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: U t
Site Address or Parcel#: 0* 12611 !EM] Inc vl(,(.e h V n v-c,
Subdivision Name: Lot#:
EXPLANATION: Pe(m�+ hCA re,�1U lir ejCl �n�-ten riot _
Signature: Date:
Print Name:
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE
Route to Sys Admin: Date li- Route to Records: Date y417 /7 B
Refund Processed: Date B Invoice Processed: Date B
Permit Canceled: Date y /7 / B —Parcel Tag Added: Date B
I:\Building\Forms\RegPerrnitAetion_ 2314. oc
VID
City of Tigard 1-
y� 7//?
PUBLIC \FORKS — ENGINEERING PGE WORK ORDER# M2042396
Public Facility Improvement (PFI) Permit
DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL
Check one: 8 Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS
Detailed description: Car hit pole# 77 and needs to be replaced. I@ :Minor work in right-of-way
(sidewalk repair,curb cut,street
Pole has since been removed. New pole will be 20'black fiberglass(16'MH) opening,etc.)requires:
and 100w HPS T&C Light. •:application form,completed
and signed
•Submit one(1)copy of scaled sketch
Property address/location(s): SW corner of SW Wilton Ave and of the proposed work to be done
SW Walnut St. Nearby address is1-+3844—SWWftmAve •Submit one(1)copy of traffic
. ,�
control plan
3 8 II Sul LiG1e n Dr. —OR—
Rachel Schoenheider ❑ Substantial project work requires
Applicant's name: above items and professional
Address: 10800 SW Avery St engineered plans for:
•
Cit</state: Tualatin, OR Zip: 97062 Street widening
•Subdivision infrastructure
Phone: 503-612-6105 Ismail: Rachel.Schoenheider@pgn.com •Main utility line extension:
Storm Drain,Sanitary-Tigard
Water-Tigard Water Service
Contractors name: Area(includes Durham,Yung City
CCB#: Expiration:
and a portion of unincorporated
Washington County)
Address:
City/state: Zip: DELIVER APPLICATION TO:
City of Tigard
Phone: ],,mail: Planning/Engineering
13125 SW Hall Blvd.
9
Engineers name:
JefferyStei leder Tigard,OR 97223
Address: 10800 SW Avery St applications for"minor work in right-of-way"
only inay be emailed to:
City/state: Tualatin, OR Zip: 97062 rowpermitsktiga� rd-or.gov
Phone: 503-672-5462 Email: Jeffery.Steigleder@pgn.com
Case No.:-f>F_.4��
Estimated value of work (within the public right-of-way):
Application submittal fee:
Is work related to a LAND-USE DECISION? ❑ les ❑p No Applica ' n a epted:
If so, please specify (MLP, SDR, SUB, etc.) case #: By: Date: Zo Its
Is work related to a BUILDING PERMIT? ❑ les Applicati n r wed:
B N° � ?.a /Zo�(o
By. Date:
If so,please specify(BUILDING PERMIT)case#:
Appjdyed:
By: Date:
I:\CUn\land Use Appkations Rev.07/16/2014
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page I of 4
APPLICANTS
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 or submit a written
authorization with this application.
BY SIGNING BELOW,THE APPLICANTS) SHALL CERTIFY THAT:
• The above request does not violate any deed restrictions hat may be attached to or imposed upon flic 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 required.
DoWy W—by Coatlinaton.
Ramat sm°mneim.
Rachel Schoenheider °"E--.�'R`�" ° Rachel Schoenheider 04/27/16
a=Fereeuis�te
anal=Ramel.Smaenneber�pgncom.c=US
Date-.2016 01 2111 01 M 4T '
Applicant/Authorized Agent's signature Print name 1>;11 c
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.tigard-or.gov • 503-718-2421 • Page 2 of 4
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M2042396
MURRAYHILL-MURRAYHILL
C21-04B