PFI2012-00025 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12012-00025
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued:
Parcel: 1 S136DC
Jurisdiction:
Site address: 7500 SW Dartmouth ST
Subdivision: Lot: 04500
Project: WINCO
Project Description: 16 LF Sidewalk Replacement
Owner: FEES
Description Date Amount
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
MARGIE COMER
11234 SE CLINTON STREET
PORTLAND, OR 97266
PHONE: 503-890-5360
Total $0.00
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 1
Signature:
Issued By: `�`t1W4-i",'4'
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12012-00025
Ty pe: Condition Name: Status: Severity:
City of Tigard
Public Facility Improvement (PFI) Permit
General Information: ,l- FOR STAFF USE ONLY
Property Address/Location(s): 14500 S w b mDu Engineering
s�('ec� � qY-� (�� �j -]��3 Case No.:
Receipt No.: /V; FEC g- 20�.Lr
/ / L Date: j -21 - /2-
*Applicant's Name: W I YlL0 / (C-V VN- Application Accepted Byz-"�
Address: Z-3 CA S I Y--1Revised 7/1/10
City/State:'?o rA�a—A, () It Zip: al Z- G,
Primary Contact: 'NZ n`i �o VAC✓ REQUIRED SUBMITTAL
INFORMATION
Phone: Fax:
Professional Engineered Plans are required
for:
Contractor's Name: rn�V^ ►"�S
1 1 �-'7 �' • Street Widening
CCB# 4 Expiration: // . Subdivision Infrastructure
Address: 1123 L� S f-- C-1 I N4-o n S • Main utility line extension:
City/State: -PO rH Y Zip: 9 - .a(o So 0 Storm Drain,Sanitary-Tigard
0 Water-Tigard Water Service Area
Phone: 0 3-?GIO"S3(-U Fax: (includes Durham,King City and a
portion of unincorporated Washington
County)
Plans By: Maya,,^n aya,,I C— Cc�Y�e-
Address: -2-3 4 S er- i�i 10-0Y\ S+ **Note:See Engineered Plan
L Submittal Checklist attached.
City/State: �or \ 1� UY Zip: '017- (c(o Sto wm-k- PtAVA /b �
For all other work Submit scaled sketch of the
Phone: 5 03 --`:69 O-S'3 I'o O Fax: work to be done. (see attached minimum sketch
requirements and provided sketch area).
Description of work: Q e t2 4(a_ 41A-)O ✓e-L�(OVI S I:curpin\master\land use application\PFI app.docx
0�- s lcfe _
Estimated value of work(within the public right-of-way): $ 1 Vb O
Is work related to a LAND-USE DECISION? YES F-] NO
If so,please specify(MLP, SDR,SUB,etc.) case#:
Is the work related to a BUILDING PERMIT? YES F-� 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 1 of 4
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