PFI2014-00066 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12014-00066
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 09/04/2014
Parcel: 2S112BC01800
Jurisdiction: Tigard
Site address: 14735 SW 84TH CT
Subdivision: HAMBACH PARK Lot: 2
Project: Elliott
Project Description: Replace 5'x 5'panel of sidewalk that was removed to repair water main break.
Owner: FEES
Description Date Amount
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
PAMELA ELLIOTT
14735 SW 84TH CT.
TIGARD,OR 97224
PHONE: 971-506-5683
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
Signature:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
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City of Tigard
Public Facility Improvement
(PFI) Permit
General Information: FOR STAFF USE ONLY
Property Address/Location(s): IWISS S'^'/ $ h `tel Engineering.,
Case No.: YF 12014 W096
Fee:
Receipt No
*Applicant's Name: LDate:
Address: n Application Accepted: y By:
City/State: r k `� Zip: Rlow
Primary Contact: REQUIRED SUBMITTAL
Phone: Fax:
�� //�� INFORMATION
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E-Mail:
Professional Engineered Plans are required
for:
• Street Widening
Contractor's Name: • Subdivision Infrastructure
CCB# Expiration: • Main utility line extension:
Address:
0 Storm Drain,Sanitary—Tigard
0 Water—Tigard Water Service Area
City/State: Zip: (includes Durham,King City and a
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:6/24/2013
_ 1:\CURPINV fasters\land Use Applications\Public Facility
Irnprovernent docx
Description of work: `til b�F11 .�X S E��iA b
Estimated value of work(within the public right-of-way): $ 500.00
Is work related to a LAND-USE DECISION? YES NOff
If so,please specify (MLP,SDR,SUB,etc.)case#:
Is the work related to a BUILDING PERMIT? YES N
If so,please specify (BUILDING PERMIT) case#:
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 503-718-2464 1 www.tigard-or.gov I Page I 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.
♦
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 �0
a
a
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 1 503-718-2464 1 www.tigard-or.gov I Page 2 of 5
DEVELOPMENT ENGINEERING FEES
1. Public Facility Improvement(PFI) Permit:
Part 1: All non-water system improvements
Engineer's estimate X 5%(less$300.00 submittal fee)
Engineer's estimate X 29,16 Plan Review
Part 2: All public water system improvements
Engineer's estimate X 12%
Total Permit Fee = Part 1 + Part 2
PFI Permit Fee Exemptions:
There will be no permit fee charged,or assurance required for the following types of work:
• Sidewalk or driveway repair(less than 20 lineal feet)
• Relocate or replace mailbox
• Ditch cleaning that does not involve regrading.
• Weephole repair
• Curb repair or replacement (less than 20 lineal feet)
• Lawn sprinkler system installation or repair
• Street tree pruning or planting
• Planter strip landscape maintenance
• Test wells
2. Addressing Fee: The fee for this service is$50.00 peaddress.
�I Env
SAMPLE 7;:
Minimum Sketch Requirements
North Arrow Property Lines & Dimension Slope of Property
Street&Street Name(s) Existing Building,Structures Utility& Street Light Poles
Proposed Work Existing Curb or Edge of Pavement Trees
Existing S/W or D/W Apron Existing Utility Locations (sewer,water,storm)
City of Tigard 1 13125 SVC Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www,tigard-or.gov I Page 3 of S
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SAMPLE SKETCH:
Edge of Pavement
I -04— Ditch —♦"'
n
Streetlight ..—•—.—.....— .r...
e. Rain Dom,
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T--Fro—p-5 cf"Se1werTirie"
Qa I No 1
Existing Existing House 1
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■ I ">> Driveway
vi
CI h I
CLO mat ICT 1
a� I j
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E
0
■I 0 I Existing Shop
C94
PowerpoleI I j
0 0
a i
property Line
I I��
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Fire Hydrant
irHydrant(FH)
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Minimum Sketch Requirements (Put "n/a"if Not Applicable):
North Arrow Property Lines &Dimension Slope of Property
Street& Street Name(s) Existing Building,Structures Utility&Street Light Poles
Proposed Work Existing Curb or Edge of Pavement Trees
Existing S/W or D/W Apron Existing Utility Locations (sewer,water,storm)
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 4 of 5
SKETCH AREA:
N
CIA
Cityof Tigard 13125 SW Hall Blvd.,Tigard,OR 97223 503-718-2464 1 www.dgard-or.gov Page S of 5