PFI2012-00027 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PFI2012-00027
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 08/29/2012
Parcel: 2S109AB04100
Jurisdiction: Tigard
Site address: 14366 SW 133RD AVE
Subdivision: THREE MOUNTAINS ESTATES Lot: 34
Project: McFarlane Driveway
Project Description: Replace driveway approach at 14366 SW 133rd Ave,
Owner: FEES
Description Date Amount
PFI Permit Fee 08/29/2012 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
BRUCE MCFARLANE
14366 SW 133RD AVE.
TIGARD, OR 97224
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 f
Signature: S C2. 1 <,04 1 0 0,
Issued By: L
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: 188181 - 08/29/2012
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12012-00027 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 02590A TLEHRBACH 08/29/2012 $300.00
Payor: Bruce McFarlane
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
RECEIVED
City of Tigard
'' Public Fac• •ty Improvement AUG 2 9 2012
• CITY OF TIGARD
' • (PFI) Permit PLANNING/ENGINEERING
General Information: FOR STAFF USE ONLY
Property Address/Location(s): (y 3 (� 5�.1 ) 3 3 Y
J Case No.: t�FI ZOi Z— 0002,
Receipt No.:
1 Date: N (2-
*Applicant's Name: 1Jr"��4 �4 r Application Accepted By:
Address: 14 3 (- ,6 S W 13 j% �V� Revised 7/1/2011
City/State:\v o� k Zip: 9 7 2
Prunary Contact: REQUIRED SUBMITTAL
Phone: �o 3 -,c-, -i 0 "�S 6 Fax; FINFORMATION
E-Mail: V S �Wks- P �r o tn'�1 c r . C CDv'- Professional Engineered Plans are required
• for:
Contractor's Name: .Te-r-� b Cdv1 Ycfi� LL, • Street Widening
• Subdivision Infrastructure
CCB# I U 9 -11 Expiration: • Main utility line extension:
Address: S W (.J� 0 Storm Drain,Sanitary-Tigard
0 Water-Tigard Water Service Area
City/State: ,'th V - LI Zip:. (includes Durham,King City and a
portion of unincorporated Washington
Phone: SO 3 5 3 8 - a, I .� Fax: Count
*"Note:See Engineered Plan
Plans By: Submittal Checklist attached.
Address: For all other work: Submit scaled sketch of the
City/State: Zip: work to be done.(see attached minimum sketch
requirements and provided sketch area).
Phone: Fax:
I:curp1n\master\1and use application\PFT app.docx
Description of work: �c�1o,e e C O C Irgic if v t U
Estimated value of work(within the public right-of-way): $
Is work related to a LAND-USE DECISION? YES ❑ NO
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 #:
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 1 of5
APPLICANTS:
To consider an application complete,you will need to submit ALL of the REQUIRED 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
(Detailed Submittal Requirement Information sheets can be obtained,upon request,for all types of Land Use Applications.)
BY SIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT:
♦ The above request does not violate any deed restrictions that may be attached to or imposed upon the subject propgM.
♦ 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,maybe 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.
SIGNATURES of each owner of the subject property.
DATED this L day of (� 5 ,20
Applicant/Authorized Agent's Signature Owner's Signature
Owner's Signature Owner's Signature
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 503-718-2464 1 wwwtigard-or.gov I Page 2 of5