ROW2014-00033 ga.if
Mi. il City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTt,/ 0 1 0
Request Permit Action y� �'`� ✓
T I G A►: I , 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
T0: 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 pi City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) ) /V/S /1 L /�+,0 /�/
Mailing Address: 42 7...5-0 SA) /7 `6 e
City/State/Zip: 776-q-/z/ l ,e) 9 7,7,2 3
Phone No.: - ,5'90 ..24/3 2.--
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
of CANCEL/VOID PERMIT APPLICATION. 72 A4CPe . Ee
6fREFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CON ' : -i - • • - ' .0 not cancel permit).
Permit#: /oItl ad/`/-400033 'X2 /9- 000/ 2
Site Address or Parcel#: A 7.S Sec) /`7 /E C` %
Project Name: /l It RA9y
Subdivision Name: Lot#:
EXPLANATION: VO/6 i OA) C426---49 j-En /N (- e-OR .
c ,q-7 - /C. .-1—c:20/y'si00/Z , /9 ! 2724'JSf
/"J AV lor- jt, "- ` 1/.Soa , a-D
Signature: Date: '4 /as /au i it-
Print Name: i l G1-(kF 10 N I TE
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b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
1 OR Oil ILI. l SI. O'\I.1
Rte to S s Admin: Date f47 gm B _] Rte to Bid. Admin: Date Qd'I B ,i17'
Refund Processed: Date ; -, M211r Invoice Processed: Date B
Permit Canceled: Date c, .epy By -= 4 '..cel Tag Added: Date By
Receipt# Date Method Amount$
I:\Building\Forms\RegPermitAction.doc Rev 05/25/2012
City of f Tigard V 0 1 0
• Public Facility Improvement
/ '/ ' ,e7c7/TIGARD (PFI) Permit
General Information: FOR STAFF USE ONLY
Property Address/Location(s): /�'7; t? $ ) Engineering no ��0OG
Case No.- 1C 11 o --
/)'� E Cr
Fee: . Q0
Receipt No.: /
*Applicant's Name: /VV/f /7 Date: ` /5 . /L/
Address: /0a7 .S .) mff,Q/G Cr Application Accepted: By:J
City/State: 77 ', 1) C Zip:
Primary Contact: REQUIRED SUBMITTAL
INFORMATION
Phone: 55 O 3- 5q o- a 4-3A Fax:
E-Mail: Professional Engineered Plans are required
for:
Contractor's Name: %}9EG/�O/l/E /-iQT'eez-49 } • Street Widening
• Subdivision Infrastructure
CCB# /7 +ZO/ �,E/xpiration: y' — �I— /9 • Main utility line extension:
Address: �f O��D /VC .Qf7�" 0 Storm Drain,Sanitary—Tigard
0 Water—Tigard Water Service Area
City/State: f/�c/E�" 1Z19 t z) '€ Zip: (includes Durham,King City and a
portion of unincorporated Washington
Phone: C5c3) X53 — 6a/g 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:\CURPLN\Masters\Land Use Applications\Public Facility
Description of work: /41 :-.)A / Improyemencdocc
Estimated value of work(within the public right-of-way): $ 5 00 • u
Is work related to a LAND-USE DECISION? YES n 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 I 13125 SW Hall Blvd.,Tigard,OR 97223 I 503-718-2464 I 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"Required 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 APPLICANT(S)SHALL CERTIFY THAT:
• The above re uest does not violate an d d res 'cuions that ma-be attached to or im.o ed u.on the subject .ro•er .
• 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.
♦ �]] 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 —llf — / day-of ,20
Applicant/Authorized Agent's Signature Owner's Signature
l wner's Signature Owner's Signature
City of Tigard I 13125 SW Hall Blvd.,Tigard, OR 97223 I 503-718-2464 I www.tigard-or.gov I Page 2 of 5
CITY OF TIGARD RECEIPT
q
�; S 13125 SW Hail Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 195579 - 04/15/2014
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
R0W2014-00033 Misc Fee 100-0000-45319 $1,500.00
R0W2014-00033 ROW Permit Fee 100-0000-43114 $300.00
Total: $1,800.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 1795 CCAINES 04/15/2014 $1,800.00
Payor: Dennis D. Murphy
Total Payments: $1,800.00
Balance Due: $0.00
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