PFI2012-00021 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12012-00021
Date Issued: 07/19/2012
R 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421
Parcel: SEG1553
Jurisdiction:
Site address:
Subdivision: Lot:
Project: Hwy 217 Management Project
Project Description: Various locations. Erosion control only.From Scholls Ferry to 1-5.
Owner: FEES
Description Date Amount
Erosion Control Only-Eng 07/19/2012 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
TOM MCCONNELL
123 NW FLANDERS STREET
PORTLAND, OR 97209
PHONE:
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
Signature: `i�✓✓
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
City of Tigard
Public Facility Improvement (PFI) Permit
General Information: FOR STAFF USE ONLY
Property Address/Location(s): Please see attached pCase No.:
Engineering _/yV/�/,,
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letter and plans for
project location details . g7API
Receipt No.: v
Date: 7-/9-f 7—
*Applicant's Name: ODOT Region 1 Application Accepted By: tt(°
Address: 123 NW Flanders Street Revised 7/1/10
City/State: Portland, Oregon Zip: 97209
Primary Contact:Becky Crockett, Environmental Manager REQUIRED SUBMITTAL
INFORMATION
Phone: 503-731-8455 Fax:
Professional Engineered Plans are required
for:
Contractor's Name: TBD
• Street Widening
CCB# Expiration: • Subdivision Infrastructure
Address: • Main utility line extension:
0 Storm Drain,Sanitary-Tigard
City/State: Zip: 0 Water-Tigard Water Service Area
Phone: Fax: (includes Durham,King City and a
portion of unincorporated Washington
County)
Plans By: Please see engineering plans
**Note:See Engineered Plan
Address: Submittal Checklist attached.
City/State: Zip: For all other work:Submit scaled sketch of the
Phone: Fax: work to be done.(see attached minimum sketch
requirements and provided sketch area).
Description of work: Please see attached letter I:curpin\master\land use application\PFIapp.docx
Estimated value of work(within the public right-of-way): $
Is work related to a LAND-USE DECISION? YES ❑ NO X❑
If so,please specify(MLP,SDR,SUB,etc.)case #:
Is the work related to a BUILDING PERMIT? YES❑ NO
If so,please specify (BUILDING PERMIT) case#:
*NOTE:Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for the work.
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page I of 4
DEVELOPMENT ENGINEERING FEES
1. Public Facility Improvement(PFI) Permit:
Part 1: All non-water system improvements
Engineer's estimate X 5% (less $300.00 submittal fee)
Engineer's estimate X 2%Plan Review
Part 2: All public water system improvements
Engineer's estimate X 12%
Total Permit Fee = Part 1+ Part 2
PFI Permit Fee Exemptions:
There will be no permit fee charged,or assurance required for the following types of work:
• Sidewalk or driveway repair(less than 20 lineal feet)
• Relocate or replace mailbox
• Ditch cleaning that does not involve regrading.
• Weephole repair
• Curb repair or replacement(less than 20 lineal feet)
• Lawn sprinkler system installation or repair
• Street tree pruning or planting
• Planter strip landscape maintenance
• Test wells
2. Addressing Fee: The fee for this service is$50.00 per address.
SAMPLE
Minimum Sketch Requirements
North Arrow Property Lines&Dimension Slope of Property
Street& Street Name(s) Existing Building,Structures Utility&Street Light Poles .
Proposed Work Existing Curb or Edge of Pavement Trees
Existing S/W or D/W Apron Existing Utility Locations (sewer,water,storm)
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 2 of 4
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 187601 - 07/19/2012
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12012-00021 Erosion Control Only-Eng 100-0000-43134 $300.00
Total: $300.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 49453 HWATKINS 07/19/2012 $300.00
Payor: OBEC Consulting Engineers
Total Payments: $300.00
Balance Due: $0.00
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