PFI2018-00155 City of Tigard • COMMUNITY DEVELOPMENT DEPARTM);NV
Request for Permit Action /�p;
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13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • vvww.figard-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 City Staff
Check(V)one
REFUND OR Name:
INVOICE TO: (Business orl"divid*
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#: Q-v702009^0015,5
Site Address or Parcel #: Wo 210D
Project Name:
Subdivision Name: Lot#:
EXPLANATION: YYYI l k VX pt ITC . N em v L SSU-QCT .
Signature: AAy Date:
Print Name: VAsKPICC L{rtv(dy —�
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 34 weeks for processing refund requests.
FOR OFFICE ITSE ONLY
Route to Sys Admin: I Date I By Route to Records: Date 3B
Refund Processed: Date6 B Invoice Processed: Date B
Permit Canceled: I Date hg Za I B Parcel Tag ridded: Date B
I:\Building\Forms\RegPermitAetion_7 5 .doe
V �_ ECEIVED
City of Tigard -1/i91Zo JUN 2 0 2018
PUBLIC WORKS—ENGINEERING CITY OF TIGARD
i N NGINEEBING
Y
Public Facility Improvement ( permit
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
❑ TYPE 1-Franchise Utility Work
Check one: ❑ Utiim ❑Sidewalk/driveway approach . ❑Streetimprovements performed by NWN, PGE
Detailed description: and/or utility agency.
r I� 1 K � C TYPE2-Sidewalk/Driveway/Sewer
190-
,�.dJL11tG T 1-k V Work performed for the purpose of:
• Sidewalk installation or repair.
Driveway approach installation
Property address/location(s): and/or repair
• Sanitary sewer lateral installation
and/or main line tap
A licanr. [I TYPE 3-Full scale Development
PP Work performed with Land use
Address: �-1 approval which includes any of
C'.ity/state: `'k) L 1 i o ZA' �.x the following.
Phone( (,05(PW0� mail: �nr • Subdivisions or Partitions
Contactname�.bTjM Phone: �0 • Street widening
/� • Mainline installation for Sanitary
Contractor. 11 sewer, Storm sewer,Tigard water
and/or Tigard Water Service Area
CCB#: Expiration: I�
Address: "�' '#• SUBMIT COMPLETED APPLICATION TO:
r��
City/state: f r ► 'Lip:CI 1m2, M , City of Tigard
Phon . O 'Ulstnail: CEO) M0VWaj1AC6fM Planning/Engineering
13125 SW Hall Blvd.
Contact name: Phone: to Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer.
only mm
may be entailed to:
r� ita[o;�1 -or.pov
Address:
City/state: 'Lip: D
Phone: Email: Case No.: PFA-20A -00 C
Contact name: Application submittal fee(.07%of
Engineers Estimate) $ SdO•O O
Estimated value of work is required(if over$5,000): �,� Additional fees:$
(within the public right-of-way) application accepted;-
Is
ccepted:Is work related to a LAND-USE DECISION? ❑ Yes No BY---&C Date.
Application reviewed: /
If so,please specify(MI.P,SDR,SUB,etc.) case#: By:.—Os-1-6 Data
Is work related to a BUILDING PERMIT? XYes ❑ No Applicant notified O
If so,please specify(BUILDING PERMFI)case#:?LM ZO j U' WW1 By.--L-� Date:
1\0MVb "Am odamW_VOp tuon rtecw.ro/rs/zov
City of Tigard • 13125 SW Hal[Blvd. • Tigard,Oregon 97223 • wwwtigard-orgov • 503-718-2421 • Page 1 of 4
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APPLICAN'T'S
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 Turd,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 owners signature on the application
BY SIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT:
• The above reonest does not violate any recorded deed restrictions that may be attached to or imposed upon the subject
• 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 approving or denying the application.
U Aft &kgk VA 14
Applicant/Authorized Agent's signature Print name Date
SIGNATURES of each owner of the subject property,if required.
Own&§signature Print name Date
Owners signature Print name Date
Owners signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www:tigard-or gov 503-718-2421 • Page 2 of 4
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