PFI2015-00172 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12015-00172
R. 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 11/17/2015
Parcel: SEG1976
Jurisdiction:
Site address:
Subdivision: Lot:
Project: PGE
Project Description: Adjacent to 14662 SW 76th Ave., PGE requests retroactive permit for work to replace a pole damaged
by a vehicle collision.
Owner: FEES
Description Date Amount
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
LISA MICHAELS
10800 SW AVERY ST.
TUALATIN, OR 97062
PHONE: 503-672-5468
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
RECEIVED
„
City Of Tigard PGE WORK ORDER#W7A76415
PUBLIC WORKS —ENGINEERING I, I
C;IT' CARD
Public Facility Improvement (PFI)i.;0
Per° 'I° l(RING.
DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL
Check one: R Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS
Detailed description: VEHICLE DAMAGED POLE 32 R Minor work in right-of-way
(sidewalk repair,curb cut,street
REPLACING 30' CL 4 POLE W/ SAME. C21-12B
opening,etc.)requires:
PGE REPAIRED POLE 11/4/15 AFTER ACCIDENT •Application form,completed
and signed
• Submit one(1)copy of scaled sketch
Property address/location(s): 14662 SW 76TH AVE TIGARD OR of the proposed work to be done
•Submit one(1)copy of traffic
control plan
—OR—
Applicant's LISA MICHAELIS /TSAHAI ANDERSON E] Substantial project work requires
Pp s name: above items and professional
Address: 10800 SW AVERY ST engineered plans for:
TUALATIN, OR 97062 •Street widening
City/State: Zip: •Subdivision infrastructure
Phone: 503-672-5468 Email: T&DSUPPORTAVERY@PGN.COM •Alain utility line extension:
- Storm Drain,Sanitary—Tigard
THIS IS FOR PERMIT AFTER THE FACT - Water—Tigard Water Service
.
Contractor's name: Area(includes Durham;King City
CCB#: Expiration: and a portion of unincorporated
Washington County)
Address:
City/state: Zip: DELIVER APPLICATION TO:
City of Tigard
Phone: Email: Planning/Engineering
13125 SW Hall Blvd.
Engineer's name:
N/A Tigard,OR 97223
Applications for"minor work in right-of-way"
Address: only may be emailed to:
City/state: Zip:
rosMermits@tigard-or.gov
Phone: Email:
NLY
FOR eel �y
Case No.: r J' � Z�' S-VV� 1 L
Estimated value of work (within the public right-of-way): O
Application submittal fee:
Is work related to a LAND-USE DECISION? ❑ Yes ❑i No App Caccepted:
If so, please specify (MLP, SDR, SUB, etc.) case #: By: Date:
Is work related to a BUILDING PERMIT? El Yes
reviewed:Yes ® No ?
If so,please specify(BUILDING PERMIT)case#: By: A_RDate:
ApWitified:
By: Date:
L\CURPLN\Masters\Land Use Applications Rev.07/16/2014
City of Tigard 13125 SQA/Hall Blvd. Tigard,Oregon 97223 arw-w.tigard-or.gov 503-718-2421 • Page 1 of 4
APPLICANTS
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 or submit a written
authorization with this application.
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_propert*�.
• 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 pertmit 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 required.
TSAHAI ANDERSON+�amNa-TSAHAIANOERSON@PGNCOM,-US n 1710 1s z3-0e�oo TSAHAI ANDERSON 11/16/15
oaTA zois
Applicant/Authorized Agent's signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • \v,,v-,utigard-ongov 503-718-2421 Page 2 of 4
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