PFI2014-00003 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
■ COMMUNITY DEVELOPMENT Permit#: PF12014-00003
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 02/03/2014
Parcel: 1 S133DD03100
Jurisdiction: Tigard
Site address: 12852 SW WINTERLAKE DR
Subdivision: VILLAGE AT SUMMER LAKE PARK NO.3 Lot: 70
Project: Cappella
Project Description: Repair one section of sidewalk due to tree roots. Section is approximately 5.5 feet long.
Owner: FEES
Description Date Amount
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
KATE CAPPELLA
12852 SW WINTERLAKE DR
TIGARD, OR 97223
PHONE: 503-639-0895
Total $0.00
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 .�c -
Signature: ( l.r/�a.Wim+/
1Q.
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
City of Tigard
Public Facility Improvement
(PFI) Permit
General Information: / FOR STAFF USE ONLY
Property Address/Location(s): f ;Z-g 57� SWI �f tu, l�� f, Engineering
Case No.: PF= R,>4-00003
Fee:
Receipt No.:
*Applicant's Name: gztl Q C_??�1_ (I Cz Date: � - 3
Address: 1!�LS�4) t/ Application Accepted: By:
City/State: f C e -,w O Q Zip: Q zz
Primary Contact. r-!:4ACUId �a r" REQUIRED SUBMITTAL
/� INFORMATION
Phone: l� d 9 3`?--&w]S Fax:
E-Mail: {'1'E'-f yKzi..,_. &r-t--e-r P :�`,7a Le C ozA Professional Engineered Plans are required
for:
/T 5 V 0 Street Widenin
Contractor's Name: l '� , L • Subdivision Infrastructure
CCB# ``-- Expiration: • Main utility line extension:
(�
Address: 10 AJ �L/lQ✓ Pr,r� 0 Storm Drain,Sanitary-Tigard
t� 0 Water-Tigard Water Service Area
City/State: Zip: (includes Durham,King City and a
5 U 3 .. '75q -0151 portion of unincorporated Washington
Phone: Fax: County)
"Note:See Engineered Plan
Plans By: Submittal Checklist attached.
Address: For all other work:Submit scaled sketch of the
City/State: Zip: work to be done.(see attached minimum sketch
Phone: Fax: requirements and provided sketch area).
Updated:6/18/2013
1:\CURP1N\Masters\Land Use Applications\Public Facdity
Improvement.docx
Description oqf_work:/7 =C oZ �-
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
If so,please specify (BUILDING PERMIT) case #:
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 1 of 5
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"Requited 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
(Detailed Submittal Requirement Information sheets can be obtained,upon request,for all types of Land Use Applications.)
BY SIGNING BELOW,THE APPLICANTS)SHALL CERTIFY THAT:
♦ The above request does not violate any deed restrictions that ma;be attached to or imposed upon the subject property.
♦ 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,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 or denying the application.
SIGNATURES of each owner of the subject property.
DATED this day of 120
Applicant/Authorized Agent's Signature Owner's Signature
Owner's Signature Owner's Signature
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 503-718-2464 1 www.tigard-or.gov I Page 2 of 5
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