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PFI2014-00033 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT = COMMUNITY DEVELOPMENT Permit#: PF12014-00033 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 07/14/2014 Parcel: 1 S 135CA01400 Jurisdiction: Tigard Site address: 11410 SW GREENBURG RD 1 Subdivision: GREENBERG HEIGHTS Lot: 7 Project: Martinson Project Description: Remove and replace sidewalk(16'x 6'). Owner: FEES WONG, NORMAN K F REVOCABLE LIVIN Description Date Amount WONG, ANN MAH REVOCABLE LIVING TRUS BY WONG, NORMAN K F&ANN MAH TR 2433 NE 11TH AVE PORTLAND, OR 97212 PHONE: Contractor: PHONE: FAX: Applicant: STEVE WINTER P.O. BOX 42566 PORTLAND, OR 97242 PHONE: 503-771-7971 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 ginning work. Permittee/Applicant Signature: Issued By: Q Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY IsCity of Tigard Public Facility Improvement (PFI) Permit General Information: r FOR STAFF USE ONLY Property Address/Location(s): I 1910 S �V Engineering Case No.: Pf Z .2 V t`fyou 3-3 111 l t��Ctl oad Fee: Receipt No.: *Applicant's Name: e ci rlr n a fA �/V561V Date: Address: P o -V'G, -1� Application Accepted: By:— City/State: Q 1,5 YJLh►t'a► C)KI zip:9 Primary Contact: G REQUIRED SUBMITTAL O INFORMATION Phone: - - 6 5- Fax: � }- E-Mail: Mq ftl S ON 10 t f rr- l Q' CCq S V e 1 Professional Engineered Plans are required (� c J fin r: 1 Qr6 J da( r�I( Re i)c)(r • Street Widening Contractor's Name: • Subdivision Infrastructure CCB# q 5 F� J Expiration: IJ • Main utility line extension: Address: 0 So � Z56{] 0 Storm Drain,Sanitary-Tigard 0 Water-Tigard Water Service area City/State: PCS Y`+I G W "Lip: IG 1.�)y 2O (includes Durham,King City and a Phone: Fax: 5 b� )ij-j 7/ -2 portion of unincorporated Washington V3—� I '-� -1 I County) ` "Note:See Engineered Plan Plans By: STRV p. �,, Submittal Checklist attached. Address: vr6 For all other work:Submit scaled sketch of the City/State: O/q��'��W 6 Q21 Zip: �� work to be done. (see attached minimum sketch Phone: ��- 0��- Fax: requirements and provided sketch area). ` I Updated:P.N\ &ste yam, 1� 2013 I:\CCKPLN\Masten\land Ose AppLcanrms\Public PxcJnv Description of work: 1 `Q' ovq_ 1 ` C e- Impvwement.d(xx c� si dewQ . Estimated value of work(within the public right-of-way): $ y Is work related to a LAND-USE DECISION? YES)��r NO JR" ©�D 710If so,please specify (MLP,SDR, SUB,etc.) case #: �`�+�/ Is the work related to a BUILDING PERMIT? YES❑ NO E If so,please specify (BUILDING PERMIT) case #: City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov Page 1 of 5 l 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. 'kWhen 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 he attached to or imposed mon 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 � \ day of � h1Me - 120 19 c canf/Auth en s Signature Owner's Signature Owner's Signature 0L+�arIL e� City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 503-718-2464 1 www.tigard-or.gov I Page 2 of 5 SKETCH AREA: S v I L _ s I V L � I s' L I � IL I � I L _ 2. I 4 L _ I � l.L — L_ IN L _ 1 � L _ I Z� L a i 1 L_ i I L _ I L _ I L i L ` APPROVED City of Tigard 13125 SW Hall Blvd.,Tigard,OR 97223 503-718-2464 www.tigard-or.gov I Page S of S