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PFI2020-00331 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Ng I ` Request for Permit Action IT,'„ -- TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • wwwr.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 ® 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). ❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit #: PFI2020-00331 Site Address or Parcel #: 9774 SW View Terrace Project Name: Trail Subdivision Name: N/A Lot#: N/A EXPLANATION: Per Kenny Fisher ill Engineering,PFI permit is not required. Driveway will be reviewed by Engineering with MST permit. 9/9/2020 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 By Route to Records: Date Tz//// By 4/O Refund Processed: Date ^//i/- BLeic(l Invoice Processed: Date By Permit Canceled: Date /z//,/Lp By 424 Parcel Tag Added: Date By \Building\Forms\RegPemvcA c eon_09S_3l .doe v r) I n RECEIVED / �.� City of Tigard ENGINEERING DEPARTMENT SEP 0 3 2020 PFI#: '° + 2t -*c3 / - p a CITY OF TIGARD TIGARD Public Facilities It1111119VOIrferct (PFI) Permit PROJECT INFORMATION _ _ TYPE OF WORK Project name: QN-LL—L- LOT ❑ TYPE 1-Franchise Utility Work Brief description of project: MQ V l 1.1 or ` -124 50 , TO performed by NWN,PGE, or utility agency Fa Gt TG (v G�VJ %..OLPy"'?0(\3 0 F t1 'TYPE 2-ROW Sidewalk/Driveway/Sewer ID�1v���� Work performed for theof:ose • Sidewalk installation o • Driveway approach in on and repair SITE INFORMATION F�(Li t-i to-y A-p t, • Sanitary sewer lateral ins Lion and main hne tap Location (address if available): t %7 74 1 C1`1 Z 2. ❑ TYPE 3-Full Scale Development Work "i.i Yp 't 4( j �i" C GI; Ti � o� el 7'L. performed with land use approval which � / / includes any of the following • Subdivisions or Partitions APPLICANT INFORMATION • Street widening Name: PI G`f .`}� pw�I f A TRAv�... • Mainline installation for sanitary sewer, T /� storm sewer, Tigard water, and Tigard Mailing address: I y'✓2.5 ' $T-1 rpp'�t water service area City/State: TI &rtg,--47 0 D l� zip: 4 01, rt"'r ❑ TYPE 4-Small Cell Technology 2 15 a s37 ( c 0 TYPE S-Tigard Triangle Phone: �O?� / � �li�✓' L�-Oa�' Email: it`Mg (And- AO k r carry'hone: NOTE: Type 1 and 2 applications may be Contact name: 1 '�tan- ', F{� M e +Y_ h 15.5.09 i`-'A•(te, emailed to rowpermits@tirard-orvov. Phone: (50_9 St 5 a tenl ( (.7?) 515 400?Email: t 1 t w15J LA In of AO 1• Conv CONTRACTOR INFORMATION 0 Same as applicant Name: 1;eki41)1 f 00 CST( (1--C CCB Number: 2I)-067 Mailing address: I1;5 3 Jc l i S I City/State: 17,0 Or— ) Zip: 5 72-33 Phone: 503 14:3 2 33 9-S Email: })vtln o s CAMC11te1, Id)mail• Gam, ENGINEER INFORMATION Name: Mailing address: City/State: Zip: Phone: Email: ADDITIONAL INFORMATION Estimated value of work is required(if over$5,000):$ (within the public right-of-way) Is work related to a LAND USE DECISION? 0 Yes 0 No Case number: "I-) '2t., z_zo — c,c_n�bZ 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 15.04.140. * With the exception of a utility operating pursuant to a valid franchise or license 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 must sign this application in the space provided or submit a written authorization with this application. Franchised or Licensed Utilities arc not required to obtain the owner's signature on the application. I, the applicant,certify that: • To the best of my knowledge, all the information provided within this application package is complete and accurate. • 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, I will exercise the rights'granted in accordance with the terms and subject to all the conditions and limitations of the approval. j2bovo ma4/1, D8/r6/2-02o A ca is or authnri7ed agent's signature Print name Date P'sa /a� ; tAsSA Taw `6/2"1/2c0 Pro r owner's signature (if required) Print name Date Case No: ,be ,40" 4039/ Permit fee: Received by: Date: e2� Approved by: Date: Notified by: Date: (`iw friTirra rri • 11175 CwT T-Tali 1th.,.i • Tirca.vi (lrr+rrnn 07991 • ammntirnr(1_nr nncr • 5m_7i R_74.71 • Pnon7/If Vicinity Map ��� View and .., 4 SW e ' erton � r Ter. t[' a `. T rgarSr; " - City of Tigard, Oregon y� -e r..;. z, • , r'n x�Y�vv "' Unimproved Right of Way xTua"faatfm ;. T toN TRIPE i Co ^" �" r 'pie, �Q'`J -.: t 'm cc Aw. a• i'f • : 4- yµ ' 3 [r,t' ^ CY"� M J o.0 re aenoa rtam mrr uvr•.o.r.•..Yne mw or nvary 3F. m e.na aMrr•praeenletlon,ar puar.nlea a.le [neecanl•nl�ae.ur•Y.t^ma lne.a or eomeplere ne.e orI or me a.r.oroaeev .rem.rn.cuY r nv.ro.nee x n rr.mnry ror anY enan a oboe a w.o.miio n rm newm isri ro.mee revrai•u m 1 II 111.11 -._:.. _ .... r(_ Se ��. �YpFl.lert skw']rrran�,.�l i Scale: 0.01 Miles City of Tigard 13125 SW Hall Blvd Tigard, OR 97223 Map created: (503)639-4171 0627R020 www.tigard-or.gov Go •. gle Maps tit { r' s �j�{ r • 4,.fi ;• � .+11 r. ,::R • ..� , �. x; 1 •�' fps!° * V tY ! 't` ,, yf . 7•.., n t - b y `S y t .,i,.: • •t v' r E ,�s i$• '�^ t I` v t 1� © # , Yx#`+ �i 8e, ikt.r' I t` Vf9AGL �T�� f1L(ti� • • ,... r; 3 id„ A4 r J , ., rY • RAF. 1• iif �4 i-±f 5 ��*T „, c. rK.o N. 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