PFI2012-00018 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12012-00018
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 05/21/2012
Parcel: 2S110AA00300
Jurisdiction: Tigard
Site address: 14145 SW 105TH AVE
Subdivision: 2011-041 PARTITION PLAT Lot: 2
Project: Pacific Health&Rehab
Project Description: Driveway repair/replacement
Owner: FEES
Description Date Amount
PFI Permit Fee 05/21/2012 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
BONDINCORPORATED
1385 DAVIS ROAD S.
SALEM, OR 97306
PHONE: 503-390-0985
Total $300.00
Please sign below to indicate acceptance of conditions and return a copy with the proposed work schedule along with names and contact
information of responsible parties before beginning work.
Permittee/Applicant — 40�
Signature: -)? /���
Issued By: (kivO
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 186816 - 05/21/2012
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12012-00018 PFI Permit Fee 100-0000-43114 $300.00
Total: $300.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 02161C HWATKINS 05/21/2012 $300.00
Payor: Mark D Bybee
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
DATE 511D 11-2
MPryp1` 5,1 '503, 50
R City Of Tigard
Public Facility Improvement (PFI) Permit
General Infortnati.on: ,FO SAF USE ONLY
.property Address/Locatiott(s): .w f.05-To Engineering
Case No.:��
Receipt No,:
*Applicant's Name: 50VO I P GU t"':1-S �ATeo
Date:_
Application Accepted By:,hav
11dd.ress: %.K- ,O A\f IS Revised 7/1/10
CityiSi:arc: A LAt� Z..ilr. � >ab
Primiry Contact: C7 � t �j p e� _ REQUIRED SUBMITTAL
r INFORMATION Fax; Q�J� 4 -- t����
Ersifeasional EnAipeered Plane akg required
Cot2tcactor's Naine: 11 _ 0
CC # _�_�n 13 _ F�:pirarian: • SrrcctWider,*
Subdivision Infhstructure
Address: , V ASI I p O _� ■ T Main utility line extension,
City/state:,'S pr M 7t f�j 0 Storm &rDrain, tstry-Tigard
O 0 Water.-Tigard Warm:Sexmcee Area
Phone: 0'— (33 Fax: 5�3�39� -'ei1p br (inckides Ourhana,King Ci,y and a
Portion o.f unincorporated Washingron
County)
Plans By:
""Note:Sec Engineered Plan
Address: Submim,0 Cheeldi,r amtchecl.
City/State: _ 7.i
-' p' For all other work:Submit scaled sketch of the
pllonc:,-,,,,„, Fam work to he deme.(Fcc attached minimum sketch
requirements and provided slteteh arca).
Description of work: ?-
DEMO, VULALC l;cu y�ln\ma:;ccr\land uxc a��pGearian\Pk l aPP,dire�
x 5'1 1 NV Cu r-p-QtC1 .- D�-1Uk.�+A`{ GE{ _ANS T[ eftNZ S10EVJAU<
r CXt'1Ri--'.- S tOP . J01PT
Estimated value of work(within the public tight-of-way):
Is work x illtted to 1 LAND-USE DECISION? YES NO FV
If so,please specify(MLP,SDR,SUB,etc.)cage##:
Is the work related to a BUILDING PERMIT? YES NO
If so,please Specify(BUILDING PERMIT) case#:
qm
*NOTE:PerAon specked as"Applicant"shall be designated t'i'eartnittee,,and Ahall provide financial assurance for the wgrk.
City ofTigt.rd f 13125 SW T):all.B1vd.,'1".igard,OR 97223 5()3- 18-2464 m7%VW.tigal-d-or.,gov I Page 1 of 4
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City of Tigard 13125 SW Ha1.1.Blvd,,Tigard,OR 97223 503-7,1,8-2464 www.ti.gard-or,gov Page 4 of 4
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Complimentary Self-Serve Fax Cover Sheet
To,"C i bA 1'�o $uo o P x`47" From: /1A!� F-�
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Fax 4.-: (o a �^ Phone #: �a 3 – ,5o – ocf-Zl,
Date: S Repl Fir ax#: —
Number of Pages (Including Cover): Urgent ❑ Confidential [] Confirm Receipt
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50
We'll do it right the first time --- guaranteed.
Black&whito copies Color eoples•Custom printing•Binding•Folding•Wide-format Copying•Diatom stamps•UPS snipping and more
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