ROW2014-00054 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
i ■�! Request Permit Action V 0 1
4 ice..
r I G A R I) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or!goc
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 El 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 (✓):
X CANCEL/VOID PERMIT APPLICATION.
El REFUND 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 CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: Y a)I-T CM-
Site Address or Parcel #: SE 2�S
Project Name: I
Subdivision Name: Lot #:
EXPLANATION: Raid I S ‘h 1116 Ccun . Pam j noF requ hrd
Signature: 4111,0 (iW it Cf- Date: (el Lib y
Print Name: //res11y iZ
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b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 Rtc to Mr Admin: Date 6 /s.- /9/ By :"
Refund Processed: Date /S//l By ILIA Invoice Processed: Date By
Permit Canceled: Date 1p j By e, By IFOA. Parcel Tag Added: Date By
Receipt# Date Method Amount$
I:\Building\Forms\RegPermitAction.doc Rev 05/25/2012
RECEIVED
MAY 272014
City of Tigard
CITY OF TIGARD
:3;4, Application for Work in the Right-Of-WayNING/ENGINEERING
ROW Permit
Property Address/Location(s):SW 150th Av @ SW Sophia Li' FOR STAFF USE ONLY
WR#3413134 SEG! 2_Erj
Right-of-Way
NW Natural Case No.: 2 2o14—tt9.
O5
*Applicant's Name: Application Accepted:Sj2 frt By: AV—
Address:220 NW 2nd Av
Portland OR 97209 Application Reviewed:Ain By:G�Yt
City/State: Zip:
Jud Doblie $300.00 Application Fee Due: Yes C No ji
1 rnnary Contact:Judy
Phone:503-226-4211 X 4428 Fax:503-273-4822
Applicant Notified:
Email:nwnpermits @nwnatural.com Receipt No.:
REQUIRED SUBMITTAL
Contractor's Name:Same 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
plan
Email:
Professional Engineered Plans are required
Plans By: for:
Address: • Street Widening
City/State: Zip: • Subdivision Infrastructure
Phone: Fax: • Main utility line extension
Email:
I:curpin\rnasters\land use apphcauuns\ruw app.ducs I Rev.7/19/12
Description of work:Make locate wire available and bring up in a 10" round frame. Main on the 11'in ROW.
Possible street cut.
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#:
...201•052,142•33471.0 5/27/2014
Signature of Applicant/Permittee: Y "a"" Date:
'
Print Name:Judy Doblie Title:Engineering Coordinator
6 • 4-,r 4ity of Tigard I 13125 SW Hall Blvd.,Tigard,OR 97223 I 503-718-2464 I www.tigard-or.gov
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