SGN2012-00148 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT J O I D
III ■ Request Permit Action 0/-A2, q
I . , , 1 i 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard - or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or individual) L. o t , . . i s F. 5.-t .0 K 1 -
Mailing Address:
City/State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (
CANCEL /VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: ,S (, 1J ao (z -oo 14 8
Site Address or Parcel #: ° F 3 0 SW Cas c R a P
Project Name: S kar.e Co •
Subdivision Name: Lot #:
EXPLANATION: FCC-3 Wert rtof c.1-ta -iL d - o o- p I i C.A.e 4 s
C e 4;1-- c o - d. 1 5o a v cc.... d A 11.4- Ca✓ d i S rt • 1
n Pe a e d •
Signature: CAL .4.. 0 . C . ai.. •.14- Date: 9 - 13 - la.
Print Name: Cke. ✓k ( A • (Gin e.s
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2-4 weeks for processing refunds.
Rte to Sys Admin: Date By Rte tozldmin: Date Q /f /a, By
Refund Processed: Date 947 /� By j" Invoice Processed: Date By
Permit Canceled: Date . / ,, B . Parcel Tag Added: Date By
Receipt # Date / Me od Amount $
I: \Building \Forms \ReqPermitAction.doc Rev 05/25/2012
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II ■ City of Tigard
Sin Permit Application
TIGA EI g CITY OF i' nARU
PLkNNING /EN' atNEERING
GENERAL INFORMATION
Name of Development, Project
FOR STAFF USE ONLY
Site •• h N 4: C e
Address/ Street Address _ Permit No.: 5 C x u i 1 - ut a iiii
Location `� '73C' `�� L3 C A. T G1� �r�j / Approved By:
i i
Suite /Bldg.# city/State Zip """/ �8'/Z*-
72 2 3
T;ycz� L' it
c;� ',- � 7 � Dat
V S
Name Receipt #: let
Property Map /TL #: / 5 j 'i DD 00/ 04()
Owner Mailing Address Suite Zoning: f1.4 u c./
Allowable Total Area: / 40
City/State Zip Phone
Tenant or Name Electrical Permit Required? lE(Y es ❑ No
Business Building Permit Required? ❑ Yes [I'No
Name Rev. 7/1/12
is \curpht \ masters \land use applications \sign permit app.doc
Sign ' G +"LS- 5 s
Contractor Mailing Address Suite
36Zcr Ham Pi
City/State Zip / Phone REQUIRED SUBMITTAL ELEMENTS
A/L A,A h b r t173 7 / j V I Z g . f $ (Note: applications will not be accepted
Oregon Const'Cont. Board License - # ( Exp. Date without the required submittal elements)
0' Completed Application Form
Proposed Q Permanent ❑ Freestanding ❑ Freeway Zr 2 copies of site /plot plan, drawn to scale
Sign ❑ Temporary ❑ Roof ❑ Electronic
(Check all that (3 copies, if a building permit is required)
apply) Wall ❑ Other size requirement: 8 x 11", or 11" x 17"
Zr 2 copies of elevations, drawn to scale
2 New sign? ❑ Alter to existing sign? (3 copies, if a building permit is required)
Sign Dimensions: 74, ifx q `O e/ size requirement: 8'h" x11", to 24" x 36"
2 Total Sign Area (sq. ft.): - , `t' El $171.00 Fee (Permanent sign, any size)
Total Wall Area (sq. ft.) ❑ $54.00 Fee (Temporary sign, any type)
Sign Data =
(Complete all Direction Wall Faces (circle one):
items in this NOTES:
section) NTl_J E W 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): r/ must include dimensions of wall face and sign
placement.
Materials: PI, P,1 f t?' i4 fief/ ♦ Wall signs do not require site /plot plans.
Will sign have illumination? 2rYes ❑ No ♦ Freestanding signs over 6 ft. required a building
Type: Ili Internal ❑ External permit.
Are there any existing freestanding or wall signs at this location,
including wall signs that overlap a tenant space?
''es ❑ No
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 oft
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
BY SIGNING BELOW, THE APPLICANT(S) SHALL CERTIFY THAT:
• 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.
• 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.
11 6/. (n a j 3 1, , 9--
Applicant Signa Date
S' e of Owner / Date
Yrc� Svuvo
Contact Person Name Phone No.
City of Tigard I 13125 SW Hall Blvd., Tigard, OR 97223 I 503 -718 -2421 I www.tigard - or.gov I Page 2 of 2