PFI2014-00067 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12014-00067
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 09/08/2014
Parcel: 2S 104BC09600
Jurisdiction: Tigard
Site address: 14291 SW LUKAR CT
Subdivision: 2008-069 PARTITION PLAT Lot: 2
Project: Mission Homes Sewer Install
Project Description: Install sanitary sewer lateral for 14291 SW Lukar Court
Owner: FEES
Description Date Amount
PFI Permit Fee 09/08/2014 $300.00
PHONE:
Contractor:
DAN RIEHL EXCAVATING
24801 SE HOFFMEISTER
DAMASCUS, OR 97089
PHONE: 503-658-8180
FAX:
Applicant:
DAN RIEHL
24801 SE HOFFMEISTER
DAMASCUS, OR 97089
PHONE: 503-658-8180
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:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
SKETCH AREA:
L
ITA
s L
N
5
City of Tigard 13125 SXX'Hall Blvd.,Tigard,OR 97223 1 503-718-2464 www.tigard-or.gov Page 5 of 5
RECEIVED
City of Tigard SEP 0 8 2014
Public Facility Improvement CITY OF T fr ARID
(PFI) Permit0 1G'10 nsw
tq
General Information: FOR STAFF USE ONLY
Property Address/Location(s): / q 9-011 S� W Engineering
k !_ L/ k/� C-t T C3 i / Case Nddo..',:--__,.,f�p�(201 q-=0—}
Fee: QW
Receipt No.:
*Applicant's Name: n 9," 42 P-,6 1 Date:
Address: !)-- V Rd 1 .5.f '1-4,1 P F f / 5 Z:0 r Application Accepted:44K__By:-&-
City/State: A 4�^ 17012 Zip: 9 72,6
�1
Primary Contact: 14 R i e 1, ! REQUIRED SUBMITTAL
Phone: 7�3 7 sR/ 5/!7 Fax: ED 3 �S 4/S'��J INFORMATION
E-Mail: K .1 P in lChL rn) ir. ho 0 D I21 Professional Engineered Plans are required
for.
r
� u // l • Street VG'idening
Contractor's Name: 2� 1 F%/7 L rX�G • Subdivision Infrastructure
CCB# l 3 J 3 U U Expiration: �f 2-1 II, • :Main utility line extension:
Address: 0 Storm Drain,Sanitary--Tigard
0 Water-Tigard Water Service Area
City/State: O Zip: 9?O S-1 (includes Durham,King City and a
portion of unincorporated Washington
Phone: 5 3 l�� `1 c1 3 Fax: 0 3 6 Ssy S S.� 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 6/24/2013
L\CURPLN\blasters\Land Use Applications\Public Facility
J /
Description of work: C G Improcement.docx
of
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 ANO El
If so,please specify (BUILDING PERMIT)case#:
City of Tigard 1 13125 S)X'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"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 request does not violate any deed restrictions that may 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.
♦ .11 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
plicant/Authorized Agent's Signature a e
Owner's Signature Owner's Signature
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 503-718-2464 www.tigard-or.gov I Page 2 of 5