PFI2014-00025 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12014-00025
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 07/10/2014
Parcel: 1 S134DBO1700
Jurisdiction: Tigard
Site address: 11200 SW 115TH AVE
Subdivision: WINTERS ADDITION Lot: 6
Project: Hufford
Project Description: New driveway approach; replace old approach with curb.
Owner: FEES
Description Date Amount
PFI Permit Fee 07/10/2014 $300.00
PHONE:
Contractor:
PHONE.
FAX:
Applicant:
JORDON HUFFORD
11200 SW 115TH AVE.
TIGARD, OR 97223
PHONE: 971-221-7107
Total $300.00
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
Signature:
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Y �
Issued By:
• 1✓
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639 4171
Receipt Number: 196758 - 07/10/2014
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12014-00025 PFI Permit Fee 100-0000-43114 $300.00
Total: $300.00
PAYMENT METHOD CHECK# CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 1066 TLEHRBACH 07/10/2014 $300.00
Payor: Jordon A Hufford
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
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RECEIVED
City of Tigard i 11 n 1�
• ' Application For Work In The Right-ofAWay
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Property Address/Location(s): 1 1�iC S�.J l( A J C FOR STAFF USE ONLY
Right-of-Way
Case No.: r 20\4'GO02S
*Applicant's Name: &a& H ECA
Application Accepted: By: Cl`
Address: ` ( IM 2 SIA i 1 5'%, j e_ 7, �P X�
Application Reviewed: -7 By:
City/State: t)R Zip: q� Z 2-
r-� �pplicant
pplication Fee Due:#300-00
Primary Contact: �2- ( o{�
Notified:
Phone: Fax: 9 6-�6 g lam`
Receipt No.: t O
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REQUIRED SUBMITTAL
Contractor's Name: INFORMATION \I
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: 'r
• Submit one(1) copy of traffic control
Email: f
plan KN per
Professional Engineered Plans are required
Plans By: for:
Address: • Street Widening
City/State: Zip: • Subdivision Infrastructure
Phone: Fax:
• Main utility line extension
Email:
Rev.6/17/2013
Isurpin\masters\land use applications\row app.docx
Description of work: ," w �v F0 G l tr ?
Estimated value of work(within the public right-of-way): $J
Is work related to a LAND-USE DECISION? YES F_� 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#:
Signature of Applicant/Permittee: Date: L
C n 'or-,�1
Print Name: 4Title:
City of Tigard 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov
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