SGN2011-00086 •
CITY OF TIGARD SIGN PERMIT
., Permit #: SGN2011 -00086
COMMUNITY DEVELOPMENT Date Issued: 08/09/2011
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2421 Parcel: 2S110DB01700
Jurisdiction:
Name of Business: BLACK ROCK COFFEE BAR
Business Address: 15290 SW PACIFIC HWY
Applicant/Agent: Black Rock Coffee Bar,
Work Description: Placement of (1) one 24 s.f temporary banner. Sign #2. Valid 9/10/11 -10- 10/11. Banner
must be placed on private property and not in the public right -of -way or visual clearance
areas.
Permanent: No Freestanding: No Freeway: No
Temporary: 2 Wall: No Electronic: No
Billboard: No Balloon: No
Banner: Yes A- Board: No
Sign Dimensions: 4'X6'
Total Sign Area: 24
Wall Area:
Wall Face (Direction): West
Sign Height: 6 ft.
Projection From Wall: in.
Illumination: No Illumination
Materials:
Electrical Permit Required: No
Building Permit Required: No
Total Permit Fee: $52.00
Conditions:
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and
all other applicable law. All work will be done in accordance with approved plans. A permanent sign must be placed within
90 days from approval date or sign permit shall expire. A temporary sign shall expire 30 days from validity date. A balloon
sign shall expire 10 days from validity date.
I
Approved By:
Permittee Signature:
elATIMI/
' City of Tigard
" = Si Permit Application
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GENERAL INFORMATION
Name of Development /Project
t FOR STAFF USE ONLY
Site /C' i ' F, I \ i; 1 C L6 I -: " C 1),'
Address/ Street Address - Permit No.: 5 6 A - 3 2 4 / (- 000 1 '
Location %<t 9i% .f l ,l,; w : • ; : t: 1'I ; t , : r; ; f
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Approved By: '
Suite /Bldg. # City /State Zip r /
' % q;;;-.:..?7, Date: 'SCI
Name r Receipt #: / 3 C"
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Property Map /TL #: 2 ' 6 4/0 t. - OIn Oc7
Owner Mailing Address Suite f Zoning: `.�
I � )lc. . � j.z /i7-! ih,i) fie..., .. .fiis ,� i --1 Allowable Total Area: IL/ S• r
Cit /State Zip Phone
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/ , Electrical Permit Required? ❑ Yes 2/No Tenant or Name
Business '' �' i• 117,- Building Permit Required? E] Yes 2/N o rir
Name Rev. 7/1 /11
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Sign
Contractor Mailing Address Suite
City /State Zip Phone REQUIRED SUBMITTAL ELEMENTS
(Note: applications will not be accepted
Oregon Const. Cont. Board License # Exp. Date without the required submittal elements)
❑ Completed Application Form
Proposed ❑ Permanent ❑ Freestanding ❑ Freeway ❑ 2 copies of site /plot plan, drawn to scale
Sign ® Temporary ❑ Roof ❑ Electronic (3 copies, if a building permit is required)
(Check all that ❑ Wall ❑ Other t » » 11" 17"
apply) size requirement: 8 /z x 11", or 11 x 17
•
❑ 2 copies of elevations, drawn to scale
0 New sign? ❑ Alter to existing sign? (3 copies, if a building permit is required)
Sign Dimensions: i /,. /. / size requirement: 8 x 11 ", to 24" x 36"
Total Sign Area (sq. ft.): 2 i/ ❑ $165.00 Fee (Permanent sign, any size)
Si Data Total Wall Area (sq. ft.) o El $52.00 Fee (Temporary sign, any type)
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(Complete all Direction Wall Faces (circle one):
items in this r NOTES:
section) N S E Of NE NW SE SW
Height to top of sign (feet): ,.' • Wall signs do not need to be drawn to scale, but
Projection From Wall (inches): must include dimensions of wall face and sign
placement.
Materials:
♦ Wall signs do not require site /plot plans.
Will sign have illumination? ❑ Yes ® No • Freestanding signs over 6 ft. required a building
Type: ❑ Internal ❑ External permit.
Are there any existing freestanding or wall signs at this location,
• including wall signs that overlap a tenant space?
9 Yes 9 N
If "yes ", a list or diagram of all sign dimensions and square
(OVER FOR SIGNATURES)
footage must also be submitted.
City of Tigard I 13125 SW Hall Blvd., Tigard, OR 97223 I 503 -718 -2421 I www.tigard-or.gov I Page 1 of 2
APPLICANTS:
To consider an application complete, you will need to submit ALL of the REOUIRED SUBMITTAL ELEMENTS as described on the
front of this application in the "Required Submittal Elements" box.
NOTE: Person specified as "Applicant" shall be designated "Permittee" and shall provide financial assurance for work.
* 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 on the back
of this form or submit a written authorization with this application
BY SIGNING BELOW, THE APPLICANT(S) SHALL CERTIFY THAT:
o 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 the plot plan, attachments, and exhibits transmitted
herewith, are true, and the applicants so acknowledge that any permit issued, based on this application, and
may be revoked if it is found that any such statements are false.
o The applicant has read• the entire contents of the application, including the policies and criteria, and
• understands the requirements for approving and denying the application.
I hereby acknowledge that I have read this application, that the information given is correct, that I am the
owner or authorized agent of the owner, and that plans submitted are in compliance with the City of Tigard.
SIGNATURES of each owner of the subject property are required.
A pplicant Signature Date
Signature of Owner /Agent Date
f/ /J///(/ 1 c% , - J -//- 7J v /
Contact Person Name Phone No.
City of Tigard I 13125 SW Hall Blvd., Tigard, OR 97223 I 503- 639 -4171 I www.tigard - or.gov I Page 2 of 2
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CITY OF TIGARD
Approved
Conditionally Approved _ �. -. _. i
For only the work as described in: p
PERMIT NO. q jdi / — c�do p Yp
See Letter to: Follow
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CITY OF TIGARD RECEIPT
,' 2 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 183594 - 08/09/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SGN2011 -00086 Temporary Sign Permit 100 - 0000 -43115 $45.00
SGN2011 -00086 Temporary Sign Permit - LRP 100- 0000 -43117 $7.00
Total: $52.00
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 073690 KPEERMAN 08/09/2011 $52.00
Payor: Justin Lesher
Total Payments: $52.00
Balance Due: $0.00
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