PFI2017-00138 City Of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action 91107
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-ongov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
Check(✓)one
REFUND OR Name: N/A
INVOICE TO: (Business or Individual)
Mailing Address: N/A
City/State/Zip: N/A
Phone No.: N/A
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
® CANCEL/VOID PERMIT APPLICATION.
❑ REFUND 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 #: PF12017-00138
Site Address or Parcel #: SEG2951
Project Name: Pro Fleet NW
Subdivision Name: N/A Lot #: N/A
EXPLANATION: Per Engineering, scope of work is on private property, not right-of-way.
Applicant was notified to contact Building Division for relevant permits.
Date: 8/3/17
Signature:
Print Name: Lina Smith
Rcfund Policy
1. The city's Community Development Director,Building Official or City I:ngineer may authorize the refund of:
• ,1ny 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 USE ONLY
Route to Sys Admin: Date By Route to Records: Date 711,V1,77 1 B
Refund Processed: Date /1/ By Invoice Processed: Date B
Permit Canceled: Date 9ZIV17 By Parcel Tag Added: Date B
l:ABuilding\Forms\RcgI)ermitAction_( 02314.doc
� t
� rr
1-410
CO
x+n
n 0
� � - Ar � F
Iv
, ���
`'��` � A' .� f .✓�6 ✓�a�r$r`"ttaA.d1' t/y'j�1 h,\{
e P
+ff"br
1
z
lr�t
i
RECEIVED
City of Tigard JUL 31 2017
PUBLIC WORKS — ENGINEERING �/Y /7"��_ CIT Y'OF TIGARD
. VEERING
oil Public FacilityImprovem nt PFre1Nr11W1
e
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
❑ TYPE 1-Franchisr l•ti?in'Work
Check onc: ❑ Utilities ❑ Sidewalk/driveway approach ❑Streetimprcxvement• performed b� N\\'\,, PGF:
Detailed description: �, CO' Q� VLty !�_ �
and/or utility a},�enct.
P"T1'PE 2—Sider►-alk/Dri\eway/svm F
\\ Irk performed for the purpose of:
-r-1 - • Sidewalk installation or repair.
• Driveway approach installation
Propemr address/location(s): ^ - �-- U ►nd/or repair
• Sanitan•sewer lateral installation
and/or main line tap
❑ TYPE 3-Fut]scale Development
Applicant: L �� F 1_�:�+ � �`� Work performed with land use
Address: 1� 1 eL /��- approval which includes any of
Citi•/state: 6 zip: "`�2(�L,. the foflowingr
G ' ' • Subdivisions or Partitions
Phone: P)l�]- � ail: iti N
� ��� �`�� � Street widening
Contact name: .-S. 1 � 4 Phone:
Mainline installation for Sanitary
1 sewer, Storm sewer,Tigard water
Contractor: k'�. k� i ► rn C.,
I 5 .end/or Tigard Water Sen•ice Arca
C.CB#: _ Expiration:
Address: �?- ct 19v C- SU BMIT COMPLETED APPIJCATION TO:
City/state: Zip: c2,u City of Tigard
Phone:�,1 �f�' I ? pail: Planning/Engineering
-----1 —.--AE1 :�`►- 4 Q i L'1� T� �-"-' 13125 SW Hall Blvd.
Contact name: Lk y
h e: Tigard,OR 97223
Applications for"minor work in ri,,ht-of-way"
I nOneer: only may be emailed to:
ronTermitsn ward-or.gov
Address:
FOR STAFF USE ONLY
Citi-/state: Zip:
Phone: Email: Case No.: �:� -ML�
Contact name: Application submittal fee: S
Additional fees: $
Estimated value of work is required(if over S5,000): t 1) Q Application accepted:
(within the public right-of--way) By: �S Date:
Is work related to a LAND-USE DECISION? ❑ Yes ❑ No Application reviewed:
By- Date:
If so,please specify (11II.I?SDR,SUB,etc.) case #:
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes ❑ No Br bate:
If so,please specify(BUILDING PER.NU f)case#: \ENGEPeMitAPplicatmns\pfi_application Rev 12/16/2016
t
City or Tigard - 13125 S\t'Hall Blvd. Tigard,Oregon 97223 • ur w.tigard-or.g(w 503-718-2421 • Page 1 of 4
APPLICANTS
NOTE: Person specified as"applicant"shall be designated"Permittee"and shall provide financial assurance for work,it
required by the city pursuant to TMC 15.041.140.
With the exception of a utility operating;pursuant to a valid franchise with the Cite of Tigard,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. Franchised
t'rilities are not required to obtain the Owncr's signature on the application
BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT:
• The above request dues not\Jolate an�-recorded deed restrictions that ma}-be attached to or impcoscd ul2on the subaect
o
• 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 any 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 Round 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.
o.. kw/41
Applic t/Aur prized Agent's signature Print name Date
SIGNATURES of each owner of the subject property, if required.
Owner's signature Print name Date
{owner's signature Print name Date
0wrier's signature Print name Dare
f
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Bled. • 'Tigard,Oregon 97221 • wxvw.tsg;ard-ongtov 503-7113-2421 • Page 2 of4