ROW2013-00012 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENV 0 1 ,!
11 =. Request Permit Action
TIGARD 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
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 (✓):
g CANCEL /VOID PERMIT APPLICATION.
n 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 #: ROA2 -01 S 00012
Site Address or Parcel #: SEG 1$2$ 5E63608
Project Name: Commas+
Subdivision Name: Lot #:
EXPLANATION: Wofk ' 4 rip-4-1 ce,(e i
Signature:
/*le/4 Date: 2-I I y j i 3
Print Name: — T1 nr1 Lek rb6t.Ck
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date By Rte to $dig.Admin: Date o 2/.2, i3 B • -
Refund Processed: Date Ai ' By a Invoice Processed: Date By
Permit Canceled: Date /2./,(3 By Parcel Tag Added: Date By
Receipt # Date Method _ Amount $
I: \Building \Forms \RegPermitAction.doc Rev 05 /25/2012
01/30/2013 03:04 5037195475 TEXSTAR ENTERPRISES PAGE 02/03
•
• APPLICATION FOR n
WORK IN RIGHT -OF -WAY (ROW) PERMIT 11111 .
1 OM
1.
,' T I G ARD
Development Engineering
13125 SW 1 -fall Blvd., Tigard, OR 97223 (503) 639 -4171 FAX (503) 624 -0752
FOR STAFF USE ONLY
General Information:
Right -of -Wa,�r
Property AddresslLocation(s); '(10$ St.,' ti} �� e,.a re4 r Case No.: KOw 2A 3 - 00012
SEG I S'7-g SEG 3 60z Receipt No.;
)
Date: 21612,013
VA *Applicant's Name: C+^' 4 Ca le Application Accepted By:
Address: 1 1 - IZGt: S g-.1 16 r i `otogGarr C Revised 3/4109
City /State: au 4c ( OR Zip: fit jS' 0" tea g ' 7 ' /3
Primary Contact: Ko,•a flrrr`s I REQUIRED SUBMITTAL INFORMATION
Phone: .503- 3 * 2 - a S? 4 Fax: S -372 - 13 t 1
Contractor's Name: er,CS�ar e"kre<<`si . -C Submit a scaled sketch of the
proposed work to be done
CCB# 11-01 'a Expiration: %O1101 -
Address: LOW N B JAt:J.Q 5-4
t Professional Engineered Plans are
City/State: �'d 69. dip 4 X21 required for:
Phone: .S-63'4 - 436 Fax: 60 -71
• Street Widening
11 ' r r • Subdivision Infrastructure
Plans By: t lt�`�� 1 Q 1 f' � � • Main utility line extension:
Address: lox, 62C. Qv,(0, 5÷
City/State: Po C4- 4414 4� Zip: Q .7 211
Phone: 6- QCQ-gi( Fax: So 3v- 14 - 3`4 7.6-`
Description of work: 3' 0 Fro-cA -I a ( tom (aZ i a{ a - f �^
`� yN ,?,..% [tlf " bee „i ( �r�dcl e a , M R G! r 0)-2
-2 f . G .�� �T 4 14 4 G! 1 Z , 1 ]�
tCftoc,P_ ta.sa 94'
Estimated value of work (within the public right-of-way): $ 102
Is work related to a LAND -USE DECISION? YES ❑ NO "i
If so, please specify (MLP, SDR, SUB, etc.) case #:
V
Is the work related to a BUILDING PERMIT? YES n NO
If so, please specify (BUILDING PERMIT) case #:
' *NOTE: Person specified as "Applicant" shall be designated "Permitee" and shalt provide
financial assurance for the work.
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5037195475
01/30/2013 03:04 5037195475 TEXSTAR ENTERPRISES PAGE 01/03
To: Development Engineering
j Fax number: 503 -624 -0752
From: Uriah Stewart
Texstar Enterprises, Inc. Fax number: 503 - 719 -5475
4020 NE Buffalo st. Email: uriahstewart @texstarenterprises.com
Portland, Or 97211
503 - 719 -5436 Date: 1/30/2013
Regarding:
Application for work in ROW Permit
- -- Phone number for follow -up:
503- 969 -6161
Comments:
Please let me know if you need anything else.
Thanks,
Uriah
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