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PFI2018-00043 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Request Permit Action , F ® 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigar -o.<ov TO: CITE' OF TIGARD Building Division Services Supervisor 13125 SW Hall Blvd.,Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 w\vw.tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff (Check one) REFUND[ OR Name: INOICV E TO: (13u11ness Or 111d111du:1.1) Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED {✓): CANCEL/VOID PERMIT APPLICATION. ❑ REFUND PERMI"T FI='ES (attach cop)7 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 #: EFT2,06 — WO!J- > Site Address or Parcel #: S'e G 2 A 6" Project Name: Subdivision Name: Lot #: EXPLANATION: 1 'E if, L4. Signature: A-MV1-/ Date: Print Name: � �r0 Refund Police I. The Director or Building Official may authorize the refund(-)I-- ,I) anv 1-cc which N as erroneously paid or collect(:d. b) not more than 80°,o of the land LISC application fee when an application is withdrawn or canceled befo>c anv rev 1cw effort has been c_xicnde.d. C) not more than 80°%0 of the land use application fee for issued permits. d) not more than 80"�i'of the building plan 1—CVww fee when an application is canceled before any plan revlcw effort has been eXpendcd. C) not more than 8W/%of the building permit lee for issued permits prior to',MV inspectIOI1 reyue.sts. 2. Refunds will bei returned to the o1winal Paver in the same met.11od in which payment was received. Please allow 2-4 weeks for processing refunds. FOR OFFICE USE ONLY Rte to Sys Admin: Date By Rte to Bldg_,admin: Date B Refund Processed: Date. By Invoice Processed: Date B',- Permit Canceled: Date /, B�- — Parcel Tat;.Added: Date By Receipt# Date Method Amount l:ABuilding\Dorms\12 cyPcrl�litAct:ion.doc Rcv 05/25/2012 i RECEWL. i FEB 21 2013 � City of Tigard CITY 0!�F T4''"' 0 PUBLIC WORKS --ENGINEERING PLAN ,T i Public Facility Improvement ('YV'%F1) Permit -a (DESCRIPTION OF WORK,(in the right-of-way) ❑ TYPE i—Franchise Utility Work Check one: ❑ Utilities 9k$idemdk/drive,,vayapproach ❑Streetimprovements performed by l VIN, PGE Detailed description: AP PPA C ATIO e-+ 0 j e.-A/ V, and/or utility agency. ❑ TYPE 2—Sidewalk/Driveway/Sewer Tt Work performed for the purpose of: :t►� �� V • Sidewalk installation or repair. c� Drivewa a roach installation Property address/I ocation(s): i U � �aL� `�`y and/or repair S t(7-2A 93 .T 1(-, 44 '3:4 e4iLz Sanita7 sewer lateral installation j and/or main line tap Applicant: CIL(':/40J tru.�'���� c L•.'��-ji�-�,� El TYPE 3---Full scale Development ppWork performed with Land use Address: R00.y 60 nf..._, t=,,�� '�' ' approval which includes any of City/state: T i L Zip: tt ZZ--! the following: Phone: �S"�S'�r 1�Oi,a ,mad: kJ--P At e-.,-� t'� eiek.•Lwe'-' cl • Subdivisions or Partitions f,J �{ a r. �'�!j'�a•, S r�� Street widening Contact name: _hC�t�v S K(kAenC✓ Phone: �l(� Cr �� • 1J/lyy cam, �Cy� • MainLinc installation for Sanitary sewer,Storm sewer,Tigard water Contractor: 14 C SE.0 E'e_.LC� `t!,✓7` and/or Tigard Water Service Area CCB#: Expiradoll: Address: $UBIISIT.COA¢!LETSYD AFkLiCATIOM T4?::,' City/state: Zip., City of Tigard Planning/Engineering Phone: Email: 13125 SW/Hall Blvd. Con tact name: Phone: Tigard,OR 97223 Applications for"sninorwork in right-of-way" Engineer: only may he emailed to: m3Werrnits Address: .... -... - - ........ ..- . -.._. __ ............. )R STAFF U tLY, ._..._... - City/state: Zip: Phone: Email: Contact name: F. ` P. En .,eevs Esumate Estimated value of work is required(if over X5,000):S ilclditiariai:#ees;�`':'''_- .___ --------- 7.-.7— _ --- ----:;.ri�' e ted:•-:: _.:_^,......___.'-�-::°:;°':'.;! (within the public right-of-way) ippicatio ec p 7. 4_.. Is work related to a LAND--USE DECISION? ❑ Yes No If so pleases eci P,SDR,SUB,etc, case#: .: $y Date: Is work related to a BUILDING PERMIT. ❑ Yes ANO ppl�cartt t, ed ,. If so,please specify case#: By if} tB UILDING PERM(� 1�EHG�Fer�lRpptxat�ohs�r!'�app�catiort EltectPie 14/1512017.. City ♦ r o 7 • ♦ • Ext} of Tigard 13225 S�� Hall Blvd. Tigard,Oregon 9 7�23 �vw�vtlgard-or gov 503-718-2421 Page 1 of 4 l k i i APPLICANTS NOTE: Person specified as`Applicant"shall be'designated"Permittee"and shall provide financial assurance for work,if required by the city pursuant to ni IC 15.041.140. '2 Wirth the exception of a utilih•operating pursuant to a valid franchise\vith the City of'ligard,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 owners)must sign this application in the space provided or submit a wfitten authorization with this application. franchised Utilities are not required to obtain the owner's signature on the application BY SIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT: • The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject r r •. • If the application is granted,the applicant will exercise the rights granted in accordance with the tenns 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 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 d'hying the application. {✓���' l iVu'-'01/x._ C-`-°l z C� /K. App t�Authori e` Agent's signature Print name Date SIGNATURES of each owner of the subject property,if required. Owner's signature Piynt name Date —Print-name----- — ---- ------Date ------- ---- Owner's signature Print name Date PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard 13125 SSV Hall Blvd. Tigard,Oregon 97223 • xvwwtigard-or.gov 503-718-2421 Page 2 of'4 f t i DEVELOPMENT ENGINEERING FEES. Public Facility Improvement(PILI)Permit: Al ®ETA APPLICATION FEE ■ MJ Part Required submittal fee 300A0 PERMIT FEE �k�.I6'EWA7t.A r i3'I'ILT'I'V Part 2: AN non-waters stem im rovemcr►ts P CC�NNEC'T`IOTS o -...:{.:::Q:.:...:......:.,th �;':::.:.::�..:Y)>._�=:._'...:.:_:..: ...... .......:... .............: Engineer's estimate X 510(less 300.00 submittal fee Engineer'sestimate 7 Plan Review _ `S SYSTEM FEE W ATER S 'n Part 3. Allublic waters stem improvements P y P :.... . - fl Engineer's estimate X 12% - e; - ❑:��s PFI Permit Fee Exemptions: - - There will be no permit fee charged,or assurance required ? LI.SCAILEVE]C.DlPll1IEN'F :,:...: 00-.010na`rttton$;an....S..t..r.e....e...t..I...m.... pra�erneifor the followingtYPes of work: s • Sidewalk re air(less than 20 lineal feet • Relocate or replace mailbox G.:Sets`24x3G,ar'2 x3.4':i'.` • Ditch cleaning that does not involve regrading. ,._.... . ....... ...... ... ...... . • \Veep hole repair : ,Q._Coffer.= ite;�icuut} � Eiie�at#on;L:egen�i • Curb repair or replacement(less than 20 lineal feet) es(City,:Water;• Sever;etc) Lawn sprinkler system installation or repair ....�. . _:.;..::<.:..�'i .:)._::...:_�,:.:.:.'__.:._:..._..:_:..:.'. ....:.•_..: _Yater Storri-ai3cl.:S.a, i:.:.:::,. Street tree pruning or planting -.- ::. ::; '.....::-. k:/Planter strip landscape maintenance Gl �lraticr.Cualit��.laciities i • Test wells apiiidT © Composste Util#kPlaii(Electrical,Phone;Gas;::.':...; • r e» r :_ '; Storm;:Sariitaty,ai'jrtei,Signage,Street fights;etc} Note. A cash assn anc say be required pe TMC 15.04.140.(customer deposit) .. S' an Aistaiice ❑ Si Lung aim Stuping Q:Street Ligf Plan: id Pliotomet�c: ;:i:`:: : ;; :° ❑ Iigineers all g EW. :=, .;':Shectaat�el��ro'ectaitl use,lariie,xe'sioi'and .._...---. piaci lad blocl,dates anci shectnwhberrj. ........ ..................:....:..:....._.::.......:....... ..... et Iii Use_onditloiis ::.::....:Storms water Dminage.Calculatspits `..❑.:�Gsote�hnical.'R�Pci�S_:.......:..-� .:.,.... . _- �:�::Prelmiiiaz�:;rl.ccess Repott(Si�ht.,Dis.tance3.: `:'.:: :: ..: :Proposed Plat,.'.;... Pathvea D :i n tf a licablc :_..❑:.:1�!ater�.7e :artirient i1' x��al..::�;�.:.� ::�-. .. . ;.:.. ..`' Etigl(1� r'S.Con'6lCtiari Skttnat PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard 13125 SSV Hall Blvd. Tigard,Oregon 97223 wwwtigard-or.gov ■ 503-718-2421 Page 3 of 4 f R n _ Y[,,. ;sao- -sr r. - .... .�,. t't'..5.kl .Z-R K, ..�+ �`�-_ -'N. :•'} '�,� `•Sk - f dv:lq� ,t T �i yL•..-.•� �'� -a. ' :- ( /..'r - L'f r-,_ „.: ,�' 'y•nrr. �'r t .fF�-- a•.x.,_. ..,_. _�. �4.' -:.`_ ,�1i,,2xf�F•<....- _ * � t '� �+r�",.•'x m'-;«, �'-,.a-,: �'j .. ,_,.-,., ,- i.;4€_-�.- � Ir �•�' f.£' -s/r'�+�r�..s 'a!:.: �.-t.��['c#:t .. �-•�,,'la., -,..:... a,,a.,;,.� }'r u,4 ..a... w�.., a,.,_ c�•,c f - •'�.a_ -T ��,it -a >atL '-sv. .: - *.' .�., t- .:. y'>' 1 �.:',•..�.;3�{{ ....•.-x ... .- k '��.. d �i'a'^ .S"-.`r .}3�.• �,ys, 'i}` .,f. ., :. ,.,, " - ,.. .., '. .,x.,.•'c pe..'�.,_...�,,:-sr .r r.,s.,_'4. ;_� ,�', � t. ,-1'a^. -.,r-z._. �-f'.c. 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