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PFI2021-00223 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT a Request for Permit Action 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • v ww.tigard-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPertnits@tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor Q City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: 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). Permit#: PF12021-00223 Site Address or Parcel #: 9515 SW Edgewood Project Name: Subdivision Name: Lot#: EXPLANATION: Not approvable per Trent Brickey in Engineering. Signature: Date: 6/2021 Print Name: Agnes UncWr Z2- Refund Policy 1. The city's Community Development Director,Building Official or City Frigineer may authorize the refund of • Any fee which was erroneously paid or collected. • Not more than 801/6 of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 I By I Route to Records: Date b B Refund Processed: Date By 0 1 Invoice Processed: Date B Dt^/ffizD PermitGWt"leeh Date (r L/ B Parcel Ta Added: Date B I:\Bu$d \Forms\RcgPc:mit9c6cn_12051 .doc City of Tigard Permit#: PF12021-00223 FNGINEF,RING PUBLIC WORKS Return to City of Tigard After Encroachment Permit Recording(For Permanent Only) PROJECT INFORMATIION� � 1 Project Name:_ VE�. d �/ 'Phis IEneroachmenr is for: ❑ Furnishing ❑ Undeggound System ❑ Privately owned Structuredlardscape *(SeeTMC 15.16 for definitions) SITE INFORMATION (Include:Site address,proposed useof right-0/-uu}',Jmrased time(rume, ronlru7orinformation, and scale drawing of encroachment and its relationship to adjoining mperties): JC- n , 15 (5 S w 0667�ao-D 5 (� Gam, biZr `�7ZZ3 uRAGK,aM AovavC, 79 APPLICANT / PROPERTY OWNER INFORMATION I is Applicant Same as Property Owners�s ❑ No Applicant Name: STACIEV ( Property Owner: !tri Applicant Address: IN Property Address: City:- C%" State:l� Zi ,,I City: e:_Zip: Ph(5 pp�� � d r!�Q �O�D7F?ma e Phone: Email: THIS ENCROACHMENT PERMIT IS SUBJECT TO THE PROVISIONS OF Tigard Municipal Code Chapter 15.16. I certify that the information provided in this application is true and correct to the best of my knowledge. I have agree to be bound by Tigard Municipal Code Chapter 15.16. Applicant Signature: Print Name of Applicant: �'TACEY Property Owner Signature: VV Print Name of Property Owner. IF INSURANCE IS REQUIRED BY CITY OF TIGARD: Insurance Policy No. Policy Expiration Date: 7Received by: NT Received Date: 6/17/2021 Permit fee: rorecl by: Approved date: Add. Fees: City Tivard • 13125 SIC-I fall Bhd. • 'Tigard,Oregon 97?13 • wunutigard-orgov • 503-718-2421 m i I R • • t • c r . -- •«