PFI2017-00051 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V
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■ Request for Permit Action V/17/17
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13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 • wwwaigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
Check(✓)one
REFUND OR Name: N/A
INVOICE TO: (Business or Individual)
Mailing Address: N/A
City/State/Zip: N/A
Phone No.: N/A
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓):
® CANCEL/VOID PERMIT APPLICATION.
❑ 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#: PFI2017-00051
Site Address or Parcel #: 8900 and 8960 SW Oak St.
Project Name: Oak Street Apartments
Subdivision Name: N/A Lot#: N/A
EXPLANATION: This is a duplicate of PFI2017-00058 that was created in error. Please void
PFI2017-00051.
Date: 4/12/2017
Signature: --�-
Print Name: Lina Smith
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date
Refund Processed: Date /`/ By Invoice Processed: Date BN-
Permit
cPermit Canceled: Date 3VI;VI7 By .IQ Parcel Tag Added: Date By
I:\Building\Forms\RegPcnnitAction_ 92314.doc
RECEIVED
City of Tigard MAR 2 g 2017
e PUBLIC \X'ORKS — ENGINEERING l CITY OF TIGARD
Public Facility Improvement (P�'I) 1 CIl I[NGINEERING
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
❑ TYPE 1—Franchise Utility Work
Check one: ❑ Utilities ❑ Sidewalk/driveway approach ❑ Street improvemen ts performed by NX&N, PGE
Detailed description: Construct frontage improvements for the Oak Street and/or utility agency.
Apt project, including curb 8t gutter,sidewalk,and LIDA facilities. Project will also El TYPE 2—Sidewalk/Driveway/Sewer
Work performed for the purpose of:
include offsite sidewalk improvements, raised crosswalk,and a concrete bus • Sidewalk installation or repair.
sheIter pad.
• Driveway approach installation
Property address/location(s): Oak Street Apartments near the intersection and/or repair
Oak Street Apartments near the intersection of SW Oak St and SW 90th Ave • Sanitary sewer lateral installation
and/or main line tap
Applicant: The Spanos Corporation TYPE 3—Full scale Development
PP Work performed with Land use
Address: 10220SW Greenburg Road Suite 530 approval which includes any of
City/state: Tigard,OR Zip: 97223 the following:
Phone: (503)272-8833 F.mail: jmauch@agspanos.com a Subdivisions or Partitions
Jared Mauch 503 272-8833 • Street widening
Contact name: Phone: ( )
• Mainline installation for Sanitary
sewer, Storm sewer,Tigard water
Contractor: TBD and/or Tigard ky'ater Service Area
CCB#: Expiration:
Address: SUBMIT COMPLETED APPLICATION TO:
City/state: Zip: City of Tigard
Phone: Ercall: Planning/Engineering
13125 SW Hall Blvd.
Contact name: Phone: Tigard,OR 97223
Applications for"minor work in right-of-way"
OTAK, Inc 0111v mac be emailed to:
L:ngineer: P i �. g
row ermrts a.ti and-or.g ov
Address: (808)SW Third Avenue,Suite 300
City/stair. Portland,OR Zip:
Phone:(503)415-2408 I:mall: kyle.childers@otak.com Case No.: PFl 20� 'DO OSI
Contact name: Kyle Childers Application submittal fee: $
Additional fees:$
Estimated value of work is required(if over$5,000):$ Application accepted:
(within the public right-of-way) By: Date:
Is work related to a LAND-USE DECISION? ® Yes El No Application reviewed:
If so,please specify (MLP,SDR,SUB,etc.) case #:
PDR 2016-00017 By: Date:
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes ❑ No By: Date:
If so,please specify(BUILDING PERMIT)case#: I:\ENG\PermitApplicatiom\pfi_application Rev.12/16/2016
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.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,if
required by the city pursuant to TMC 15.041.140.
* Wlith the exception of a utility operating;pursuant to a valid franchise with the City ofTig;ard,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 signs this application in the space provided or submit a written authorization with this application. franchised
Utilities are not required to obtain the owners signature on the application
BY SIGNING BELOW,THE APPLICANTS) SHALL CERTIFY THAT:
• The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject
ro
• 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 any 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.
Z:2z'4�// :S Aoe,14 3
pplicant/: uthorized Agent's signature Print name Date
SIGNATURES of each owner of the subject property, if required.
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 Shy'Hall Blvd. • Tigard,Oregon 97223 • wvvw:tigard-or.gov 503-718-2421 • Page 2 of 4