ROW2013-00021 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
III
Request Permit Action V . 1
3 t ry
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- r. ov
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 W 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 ( ✓):
CANCEL /VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: ROW 2013 — 0002-1
Site Address or Parcel #: SEG (31 S SEG 616
Project Name: port - land C,ene,ral El . e.
Subdivision Name: Lot #:
EXPLANATION: butO i c-o e of Roy \ h_013 - OOO ZO
Signature: J// / , Date: 3/11 / i3
Print Name: Tim Le hlrback
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 °/u 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.
FOR OFFICE USE ONLY
Rte to S s Admin: Date B Rte t...:._.:= Admin: Date B "V
Refund Processed: Date Al , B 2741111 Invoice Processed: Date B
Permit Canceled: Date 4 // / 3 By ,i ; rdrAl- Parcel Tag Added: Date By
Receipt # Date Method Amount $
I: \ Building \ Forms \RegPermitAction.doc Rev 05/25/2012
Mar. 7. 2013 11:08AM PGE WLC No. 0083 P. 2
VO D
City of Tigard MAR
Z. App for Work in the Right -Of Way eir
Ni T IC A RD
TIG.!1iZD ROW Permit D�ISION
•
Property Address /Location(e): (3 T o .3 1 s S FOR STAFF USE ONLY
5 Ett7A - 1 J 1 f -1 Right -of- -Way {n��� ''
Case No.: 1�i got "_ -(Jl��
*Applicant's Name: I] • 1 I •► l 'ia. 111 Application Accepted:_ Byk i
Address: 94Y0 60eck tra n
Application Reviewed: _ By:
City/State: IAA I Vi (( ! 0 I ' Zip:. q 707D
$300.00 Application Fee Due: Yee I: No CI
Primary Contact: h_ 40.) 5 r30
Phone; .
5U3 57127 Z i t ! x:56, 7 5 Y/D Applicant Notified:
Email:
60, f ?oi s hp.P'k. Q P6iV. W m Receipt No.:
REQUIRED SUBMITTAL
Contractor's Name: INFORMATION
CCB# Expiration • Application form, completed and signed
Address: _ • Submit one (1) copy of scaled sketch of
City/State: Zip: the proposed work to be done
Phone: , Fax: • Submit one (1) copy of traffic control
•
Email plan
Q Professional Engineered Plans are required
Plans By: PC, C for.
Address: SL(.Yy1 C • Street Widening
City/State :_ Zip: _ • Subdivision Infrastructure
Phone: Fax:
• Main utility line extension
Email: imuph\nnstea\hod use appki dansl1Cvlpp.dax 1 Rey- 1
Description of work: a - 1 : _ A 1104-t- • ' IS /J W. _ . I.
Estimated value of work (within the public right -of -way); $
Is work related to a LAND -USE DECISION? YES ❑ NO Va
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 #:
Signature ofApplicant /permittee: 66 Date: __r / /43
Print Name: ■3dA) 101.4 V& Title: 3Ob PVvCe,44 i n j.
City of Tigard I 13125 SW Hall Blvd., Tigard, OR 97223 I 503- 718 -2464 I www.tigard- or.gov FEB 2 7 2013
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