PFI2012-00034 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12012-00034
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: SE 3
Parcel: SE10/03/2012G3994
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Clean Water Services
Project Description: Adjacent to 10860 SW 89th Ave.,sewage storage project.54"concrete pipe.Two 72"and one 84"
oversized manholes. 8& 10"sewer pipes to serve adjacent homes.
Owner: FEES
Description Date Amount
PFI Permit Fee 10/03/2012 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
JOE DVORAK
2550 SW HILLSBORO HIGHWAY
HILLSBORO, OR 97123
PHONE: 503-547-8117
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:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12012-00034
ems: Condition Name: Status: Severity:
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Receipt Number: 188619 - 10/03/2012
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12012-00034 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 310429 TLEHRBACH 10/03/2012 $300.00
Payor: Joe V Dvorak
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
RECEIVED
OCT 032012
City of Tigard CIF TIGARI�
Public Facility Improvement (PFI�1# ING
General Information: �r FOR STAFF USE ONLY
�Property Address/Location(s): sW �, 1A� ���� LL� Engineering
6 b SW ff'l it �V�. Case No.: QF 1A 2 OOC3�4
Receipt No.:
CW
c
Date: b
*Applicant's Name: 0 C J Application Accepted By:
.Address: 2-S50 SW Revised 7/1/10
City/State: C1Ms6t'O ` Zip:
Primary Contact: IFREQUIRED SUBMITTAL
Phone: 5Q 3- 541-4611-7 Fax: INFORMATION
Professional Engineered Plans are required
/��. _
1 f4ac
Contractor's Name: 5 I.}�.an Nridefson
56-7
` • Street Widening
CCB# 'h 3 Expiration: • Subdivision Infrastructure
.Address: 3p5,60 SW Mm Gi , p, • Nlain utility line extension:
ty 1 0 y+lcna , 0 P, Zip: -l�7i 0 Storm Drain,Sanitary-Tigard
Ci /State: II 0 Water-Tigard Water Service Area
Phone: 563-` o i- 10011 1 e`mai l: (includes Durham,King City and a
S�anafldefsonbui�ers@MSAGo Portion of unincorporated Washington
M County)
Plans By:
**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
-L requirements and provided sketch area).
Description of work: 5eyjaf_ -s+orQ.Q e_1I.curpin\master\land use application\1TI app.docx
Estimated value of work(within the public right-of-way): s 06}00(D
Is work related to a LAND-USE DECISION? YES F-] NO-Z
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 SVG'Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 1 of 4