ROW2012-00059 III q VOI
. Community Development �� �Z ,
TIGARD Request for Permit Action
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 wwwtigard- or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
® CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach receipt, if available).
❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below).
❑ REMOVE CONTRACIOR FROM PERMIT (do not cancel permit).
Permit # : ROW2012 -00059
Site Address or Parcel # : SEG1220 Adjacent to 9855 SW Walnut Place
Project Name: Portland General Electric
Subdivision Name: Lot # :
EXPLANATION: Duplicate permits were processed. One application was faxed in and the
other was sent via e -mail. Please void permit # ROW2012 00059. No fees were charged for
ROW2012- 00059.
Signature: ('u- 0 -_, Date: 7/5/12
Cheryl Caines
Print Name:
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date By Rte to.l Admin: Date 7 /f /2__ By .('
Refund Processed: Date AS/ 4 By j'• Invoice Processed: Date By
Permit Canceled: Date 7 AF - L By / Parcel Tag Added: Date By
Receipt # Date Method Amount $
I: \Building \Forms \RegPermitAction.doc Rev 07/26/07
Jur.. 25. 2012 2:07PM :G'% 4+JLC No. 3228 P. 2
RECEIVED
APPLICATION FOR JUN 2 5 2012 '
WORK IN RIGHT -OF -WAY (ROW) PERMIT o
C G- tt,JARD
PLANNING /ENGINEERING TI GARD
Development Engineering
13125 SW Hall Bhrd., Tigard, OR 97223 (503) 639 -4171 FAX. (503) 624 -0752
FOR STAFF USE ONLY
General information: WR 678813
Right - of - Way
Property Address /Location(s): 9851 SW WALNUT PL TIGARD Case No. " ;716?/ - • C "
Receipt No.:
'Applicant's Name: Portland General Electric Date:
Address: 9480 SW Boeckman Rd
REQUIRED SUBMITTAL INFORMATION
City /State' Wilsonville OR - Zip: 97070
Primary Contact: RALPH REISBECK
Phone: (503) 570 -4409 Fax: (503) 570 -4420
• Submit a scaled sketch of the
proposed work to be done
Contractor's Name: N/A D
CCB# 9 � Y Professional Engineered Plans are
Address:
c8. required for:
City /State. • Street Widening
Phone: I • Subdivision Infrastructure
• Main utility line extension:
Plans By:
Address:
City /State. _ Zip:
Phone: Fax:
Description of work: UPGRADE TO 200 AMP 3 PHASE SERVICE TO CAR WASH
Estimated value of work (within the public right -of -way): $
Is work related to a LAND-USE DECISION? YES U 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 #:
*NOTE: Person specified as "Applicant" shall be designated "Permitee" and shall provide
financial assurance for the work.
settings\temporary Internet files \content.outlook\4secmmt0 \wr 678813 city of tigard
permit.docx
APPLICATION FOR 111 , 44
WORK IN RIGHT -OF -WAY (ROW) PERMIT
Development Engineering TIGrARD
13/35 SW Hall Blvd.. Tigard. OR 9 -223 (503) 639011 FAX: (503) 624 -0 -52
FOR STAFF USE ONLY
General Information: WR 678813
bs
Right-of-Way 1C - 000
Property Address /Location(s): 9 SW WALNUT PL TIGARD Case No.:
Receipt No.:
*Applicant's Name: Portland General Electric Date:
Address: 9480 SW Boeckman Rd
REQUIRED SUBMITTAL INFORMATION
City /State: Wilsonville OR Zip: 97070 6. Z 8 /Z 2U $30042-
Primary Contact: RALPH REISBECK
Phone: (503) 570 -4409 Fax: (503) 570 -4420 Submit a scaled sketch of the
proposed work to be done
Contractor's Name: N/A
CCB# Expiration: Professional Engineered Plans are
Address: required for:
City /State: Zip: • Street Widening
Phone: Fax: • Subdivision Infrastructure
• Main utility line extension:
Plans By:
Address:
City /State: Zip:
Phone: Fax:
Description of work: UPGRADE TO 200 AMP 3 PHASE SERVICE TO CAR WASH
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 II
If so, please specify (BUILDING PERMIT) case #:
*NOTE: Person specified as "Applicant" shall be designated "Permitee" and shall provide
financial assurance for the work.
ohn(haPV�ztz ocal m;c,oscfl \windows \temporary internet files \content.outlook \iodv2wnd \wr 678813 city of tigard
permit.docx