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PFI2018-00042 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V = Request for Permit Action ��/ !OVR 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 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor [1(Ci Staff PP tY Check(✓)one v✓1 , REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: PL ASE 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 #: Site Address or Parcel#: Project Name: Subdivision Name: Lot #: EXPLANATION: -'ht, c4l"4, vvr 4;; -)d �flltj cAr L-It rt cf w L crt,- 1( ' wclt ����c4a 0AJ nof a—,). �( i3S I fit* Ik Sri G��� All 4r � )�. Signature: Date: Print Name: Sww-dC oala,� Refund Polices, 1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of- Any £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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. OFFICEFOR Route to Sys Admin: Date By Route to Records: Date Refund Processed: Date /V By Invoice Processed: Date B Permit Canceled: Date r,Ile B arcel Tag Added: Date B I:\Building\Forms\RegPermitAction_0923 4.doc Show Invoice Detail Page 1 of 2 Invoice Detail Permit ID M PF12018-00042 Invoice M 203968 Invoice Date: 02/28/2018 16:01:03 Period Fee Item Qty Fee FINAL PFI Permit Fee 490 $490.00 Total Fee: $490.00 https://ay.accela.com/portlets/fee/showReceipt.do?mode=show&RECEIPT_NBR=203968... 3/19/2018 COVERS EET Case # p FZZo t?-Ooo� 2- Address: Address: q 3S Sy A�A. PFI2018-00042, associated with 9350 SW 701h Ave, will be receiving revisions from ProFleet NW. Sam Copelan has already notified Al Dickman in Engineering that changes will occur. If any revisions appear in the ROW inbox, please notify Al Dickman. -Sam Copelan, Assistant Planner 2-28-2018 kw SIA PX i � l Q a� qpl-it4 r- ' -�h fQ� oU, l� r�c J� ;f PffIA-0006 -1 fTit 01j Prz t ��- f� Pjo d t. fiult 41/c � (L 4� �v Get yf l l J • RECEIVED FEB 21 2018 City of Tigard CITY OFT"'ARD BI It \\( Wk, I•.\(11\1P L A N N 1 C i,i,t1t 'I € E R I N G -ement (PH) Perinit -ov I'u��1c Facill-tv irnpi. TYPE OF NVORK DESCRIMON OF),VORK (in the right-of-%%ay) FN PE I — I bV\N, PG1 Wtalled c1czct,11111441: 4_) -1-.. Dnniv,.o. ypr,-.ich mi-I-A'ar:4 Propert% addres�, 1�,catlmi(_sll: 2) :1 o1/1A a-d ,'r 1%pair %*10 :N.jmr.try soxcr 1xvra! in J 111.1111 1111L r.ip TYPE 3—Vull caL Dv\vloptnov. A,w• I-k:r1_0rm%:d\%uh Lind us,.- or 13.irijmllj< • st rs s.i\�ith Ivy I, Contact name: - • xlwilln' 111�1.111.1n"n for HCl\ CWitt"Ictor: CB 4: :'T)d 1,'T Tiujrd\\1hT'SL-r%ict \rva L. SL JBMI 1'('O.#4[Pi-l'*Ft-.D.ALPPIJ(:A'fl()N TO: Ot\ SMIC: Zip. 01\ of Tig..Xvd �vx_ UAA L Plan ninglEnginecring JDnh Y1 res &MP)uMbb�ui 1 13125 S\\ Hall Bbd. ( WILIct r vi), _0 Tigard,OR 9722.1 AddrCSS: FOR STAFF USE ONLY PH 2-01?--0004L 54 7e F.,tlnvmcd ,fv%twk is requi rcd It 4 1%C-1- 7_*0 It fk.k-•- 's,xvIL11111 dic I-Mbfic right-o1-wat7ff Mccc 111C \pp!1C.lrj( A14 I. Ill 3c- DIM:: Is work- rJecd t,).i ).NN D 1. S.I DI.('1S1( )\ IM, Appilic.tl "rt_�, If �,(), plca,c spcc;f\- MIT, SDR, SL'K C.N 7': 77 \ppllculk oz 0aw I t so.plea"L:"Peoft �BUI 1.1 A V I PIA I H B sc Dar'.. Cit\ Of-Tigard 1 4 )itt--tw 9'22 31+; IS 2121 - AVe I Of NOTE: 1,,— !1 }�.11i11iI �}i��Ii�.t1][ ,l::;ll b, C}��i�,1],itlll �it'Tllllt[l'l ::111 `ll.:E! i`rtlLi(lt' t;'.l.ttttii:l� a��llT.11llt Itrl mo1'h,[t !l'lltal'�lI 1)1' [I}L Ci:' l liC:i:.l!]t T+r INV 11:{.. r'.. •.l s:{! :¢} ,.'111!_1'r. .E r. ;i�il•. t�:ti1'[l+ ( It. +s: [l:_ .`1_ �., �. .. 1 :!i1!�� .l+tl,.Ir t:!1 i+ •lit[.t. it !tl•r�l..it.• .j` ..7: tFi.a th 1't !'1.'�.1:r`. t`. �. -1 - l�..11 1:1 P: .•fit.`ti v It!: flrl.31 ,.1.!-1 f: . . ..i. r.. li 1 I.r .. . 1_. :i!•11 (�!� :1` � !�... ,ti r' ft.., '/t '(• •�11,+. ( !'1 sr,. {�(`_t f,.•if -.r:�lft„r t"r.,l: . i�` .It �:':+ [ I`. .�Tl��l.f'r .It +l.Illl' .+! -� r.+t.1r..1 t .till 11 i •tl I++ + s: BY SIGNING BELOW',THE APPLICANT(S) SHALL CERTIFY THAT: • .I.}1l .11r 1\ lit!C-11t i1 1 It rI,l1i .i r]4 Cl'l�rr"lily lttllt o`t�[1 it lit,il� Fll.1[ 311.; �l .ti[al i ii ii I++r/[ !f1]��+'�l_C�urf in I ltl1 .T+JIN M. • It t1]l :!}�},lica[t,•n i�;rrantcll, the a},},hl.lilt �l ll1 l�.crci;r the right••�r.lnt�ll itt art�rrljanrc��-ith lla tl rm, .lull,tibiccl tt,,!I(the Ct%'ltlit it►Ili mll} aq-'pr'"A. • 1I!r,t EEl<.il�,Ll �t.tI111111it�:11►tI 17it �1atl.iiet?1:> t:1 :'i: t):u; Ell.!!1,.1tIaC1il71tl}Zi�..l;Zlt C�:,;i]iT" Cr.l'1""11IFCll 1llrl\l It}I.Aft 11-11%.. '(71141 the .Ippjicall[�- ll,b.tscll on Ou:app ic:Itit,1]. nlar be nLI,, Ld if it 11 t„u111) tilAt .In; Iucl1 �[:►t1:t11�ilta arm [:►1��. • 1 Ell .I}�}l}ll.tli'. ilAN ft-Ali tllc t'11111-1'Cir1111'1t�1 irlCliidlti`tilt lurlii.c'� ;:'i1.t'il:rtar ai]CI UT)iIl'Y�I.Iilll� [l'it' 11Ltlul1Lt1tctl[1 It tilt,t 11 lll:llt 11w 0Ic+llll-ilcailr lt1 tli c :: �tlrilr rT1Lc11 l sc'11[ • •:i:l:ttll�r Print nan).c 17:�Ic SIGNATt,RES of each.owner cif the subject property, if is quired. ..1I11 11,1011 ��"11C f� cjitTY.tIUfs` -- _,__._..�— I1I'tF1t [1.it11i--_—_—__._--------_----------• [):11:�---—• ---- �)t`,i1LTr� •'�.i:;t't-i ��tt.tt i`sttll: �)aIC PUBLIC FACIL1 Tl IMPROVEMENT PERNII T City ul Tigard 4 E':NA1{.!fi 1�1�'.i 1` 1 i. ?, , 7; �_�►.*t .lit' i: :�,; 'I ti '1 1 Page 2 of 4 ' 2/19/2018 9350 SW 70th Ave-Google Maps IV � 9350 SW 70th Ave S Map data 02018 Google 10{t https://www.google.com/maps/place/9350+SW+70th+Ave,+Tigard,+OR+97223!@45.4524098,-122.7481004,21 z/data=!4m5!3m4!1 sOx54950c8e28a55c91:Ox6296bb11e021 e317!8m2!3d45.4525058!4d-... 111 CCB Contractor Search http://search.ccb.state.or.us/searchibusiness_details.aspx?id=185634 Ponstructon! iontractors oard BUSINESS DETAIL Licensee : PRO FLEET NW INC Address : 4125 SE 102ND AVE PORTLAND OR 97266 License No. : 185634 License Status: Active Date First Licensed : 2/24/2009 Expiration Date: 2/24/2019 Entity Type : Corporation Phone : (503) 946-1733 Endorsement Type : Residential General Contractor Workers' Compensation/Independent Contractor Status : Nonexempt ADDITIONAL BUSINESS LICENSES AND CERTIFICATIONS CERTIFIED LEAD-BASED PAINT RENOVATION (LBPR) CONTRACTOR LICENSE: YES Expiration Date: 01/12/2019 Required to bid and work on pre-1978 residential structures. OTHER BUSINESS INFORMATION WORKERS' COMPENSATION INSURANCE INFORMATION Coverage Carrier Policy No. Employee SAI F 799452AR Personal Election None None LIABILITY INSURANCE INFORMATION (History) Company Amount Effective Through UNITED SPECIALTY INSURANCE COMPANY $1,000,000.00 4/10/2018 SURETY BOND INFORMATION (History) Type Company Amount Effective Through Residential RLI INSURANCE $20,000.00 2/24/2019 COMPANY Commercial None None None ASSOCIATED INDIVIDUALS 1 of 2 2/28/2018,3:32 PM CCB Contractor Search http://search.ceb.state.or.us/searchibusiness_details.aspx?id=185634 Family Corporate Officer KETTNER, BRENT MICHD Family Corporate Officer KETTNER, GWEN MARIE RMI Owner KETTNER, BRENT MICHE/ Click here to see past associated individuals' names. ASSUMED BUSINESS NAMES(S) PRO PLUMB NW PRO ROOF Click here to see past assumed business names. BACK BACK TO CCB HOME I BACK TO SEARCH ©2018 Oregon Construction Contractors Board 2 of 2 2/28/2018,3:32 PM Short Duration Operation ck Using Flaggers < > ..� a � a A I t <-4 > JA i A V#1�1•LOC�O�1 , owls ■�� �C�VsF•ds MV TMA Odh cov"dl c Sfftr Nom/r '!'�•'0•r�r ,—_ � r C +1 • Cmh4wOift ..1w • wt'air w+�+•ICI'il0r1 M/ it� 't$! 1� SIC � • Wr lhAn►1S IIM�{JIN v! » xr_9W.Soo w Varimbl•LDCMbw A+ T A� • A At i sear s i I Y ' Diagram No. 325 ""�" Shoulder Work with Minor Road Encroachment n hy . <ROAD I Posted Slgn C1 ORK • Speed Spacing ft Buffer (mph) A B (ft) __- Initial • 30 50- l Warning SI A • or less 100 100 100 I lA 1 Q Sign g 35-40 350 350 250 0 45-55 500 500 350 • • (Optional) • • • Truck Mounted Buffer Attenuator • (Optional) i 10, minimum4 • • I j A ROAD NARROW (Optional) i B ROAD AHEAD Initial Warning Diagram No. 300 Sign Page 63