PFI2019-00059 VOIDED
PFI2019 - 00059
TURNER
CONSTRUCTION
City of Tigard COMMUNITY DEVELOPMENT DEPARTMENT V 0
111 2 Request for Permit Action
3/2"/
s
T I G A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.
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: n Owner .\pplicant ❑ Contractor ® City Staff
Check(✓)one
REFUND OR Name:
INVOICE T O: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
Z 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#: PFI2019-00059
Site Address or Parcel#: SEG862
Project Name: Turner Construction
Subdivision Name: N/A Lot#: N/A
EXPLANATION: Applicant requests to cancel permit. Please void.
2/20/2019
Date:
Signature:
Print Name: Lina Smith
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• Not more than 80%of the application or plan review fec when an application is withdrawn or canceled before review effort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 3/hf' /J B —
Refund Processed: Date /P9 By ,•q' Invoice Processed: Date By
Permit Canceled: Date 3/21/7 By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_'0923 4.doc
v n 1 RECEIVED
1-3/i t i tK- FEB 19 2019
Cl of Ti card CITY OF TIGARD
g PLANNING/ENGINEERING
, " PUBLIC WORI{S —ENGINEERING
1111i
Public Facility Improvement (PFI) Permit
T IGARD -J
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
0 TYPE 1—Franchise Utility Work
Check one: 0 Utilities ,idewalk/driveway approach ❑Streetimprovements performed by NWN, PGE
Detailed description:
and/or utility agency.
rie Ci Vey t4 fi 1,,- ` >c rte-- J2. SI --*-rt 7TYPE 2—Sidewalk/Driveway/Sewer
Work performed for the purpose of:
' ��, P��i��
• Sidewalk installation or repair.
Poi-', 1.4%v,1-s-- , iNc, f/cf-teugtifto ,A AltrltreAr' tJA-7
Property address/location(s): /i)2 3 3" c�r"4~e-- • Driveway approach installation
6'2—
and/or repair
S. -C--} g 6 2 - • Sanitary sewer lateral installation
and/or main line tap
ri;f3.,..y4.Applicant: 6r+SrK -17 ❑ TYPE 3—Full scale Development
Address: 1/5-5- 5 1 tiit a54',--1 S7-, 06,"1:›
Work performed with Land use
approval which includes any of .
City/state: R_Psn- -rJ P i v� Zip: q7z 15'g the following:
Phone:3 -5 7112-24/41 mil: lyre;ci Ca 'c o. C�-ry� • Subdivisions or Partitions
Contact name: F'r14T d h3 7 x "�+9`1 • Street widening
� Phone:
�' • Mainline installation for Sanitary
Contractor: -I;12-'44* 6,--IS r`'"11"'" sewer, Storm sewer, Tigard water
CCB#: (0 Q�6 and/or Tigard Water Service Area
j Expiration:
Address: 5' �t )Pt° 9S /96c"10 — SUBMIT COMPLETED APPLICATION TO:
City/state: Zip: City of Tigard
Planning/Engineering
Phone: Email: 13125 SW Hall Blvd.
Contact name: Phone: Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer:
only may be ernailed to:
Address: 3ef. 5w ,Lti 7 '� sowpermitena ttgstrd-or.gov
Ci /state: ��r� , ' '� r t It •i i ! i i „�i
City/State: Zip:
Phone:. 43--M Zf '11P Email: oro'4i^d e-v I k,--'Yrr. Case No.: PI ZX I CI —000S 9
Contact name: igP-t'9r-' p� '', Application submittal fee(.007%of
Engineer's Estimate) $
Estimated value of work is required(if over$5,000):$ D Additional fees:$
(within the public right-of-way) Application accepted: )
Is work related toLAND-USEBy: 0 Date: Z/ i ci 1 i'i
a DECISION? 0 Yes 14No
If so,please specify (MLP,SDR,SUB,etc.) case#: Application reviewed:
By: Date:
Is work related to a BUILDING PERMIT? ❑ Yes 0 No Applicant notified:
If so,please specify(BUILDING PERMIT)case#: By: Date:
I:\ENG\PermitAppliations\pfi application Rev.10/16/2017
City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 1 of4
APPLICANTS
NOTE: Person specified as"Applicant"shall be designated "Permittee"and shall provide financial assurance for work,if
required by the city pursuant to TMC 15.041.140.
With the exception of a utility operating pursuant to a valid franchise with the City 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
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
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 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 ap.roving or denying the application.
A
IS ' liAto• 21/g111
Applicant/Authorized 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
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 2 of
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