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PFI2021-00187 .a. City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT or-Ic = Request for Permit Action 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 •www.tigard-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigatdBuildingPermits@tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor ❑x City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) 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). Permit#: PF12021-00187 Site Address or Parcel#: Project Name: PGE Subdivision Name: Lot#: EXPLANATION: Duplicate of PF12021-00175 Signature: Date: 6/29/2021 Print Name: Agnes 0mor 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. ' OFFICE USE ONLY Route to Sys Admin: Date I By Route to Records: Date (p12-1 B Refund Processed: Date By 04 Invoice Processed: Date B Permit Canceled: Date z./ B Parcel Ta Added: Date B 1:\Building\Forms\RegPemiltAction_1 151 .doc V g D' City of Tigard '%f�4V A2 D PFI#: 2021-00187 = ENGINEERING DEPARTMENT Public Facilities Improvement (PFI) Permit PROJECT INFORMATION gi�3 TYPE of WORK PGE Jobs # M3027465 AND M29§ Project name: scription 8 TYPE 1—Franchise Utility Work of project: #101-1 to UG Conversion&Install UG Service to 2-Pack MeterBase performed by NWN,PGE, or utility agency THIS REQUEST IS FOR ONE PERMIT FOR TWO JOBS ❑ TYPE 2—ROW Sidewalk/Driveway/Sewer #2 CONVERTING TO 2GANG MB FOR (2)OH SERVS, ADDING ADU Work performed for the purpose of • Sidewalk installation or repair • Driveway approach installation and repair SITE INFORMATION • Sanitary sewer lateral installation and Location (address if available): 11047 SW Errol St AND 11045 SW Errol St main line tap SEG 1041 D TYPE 3—Full Scale Development Work performed with land use approval which includes any of the following: • Subdivisions or Partitions APPLICANT INFORMATION • Street widening Name: PGE DENISE C H O I N FOR LINDA OTT • Mainline installation for sanitary sewer, storm sewer, Tigard water, and Tigard Mailing address: 2213 SW 153rd Dr water service area City/State: Beaverton, OR Zip: 97003 l] TYPE 4—Small Cell Technology ❑ TYPE 5—Tigard Triangle Phone: CREWCOODI NATION-WESTERN@pgn.com Email: Phone: NOTE: Type 1 and 2 applications may be Contact name: AMY SWEANY emailed to rnwpermits;(&,ti•arl d-or,K)v. Phone: 503-612-2935 Email: CONTRACTOR INFORMATION 0 Same as applicant Name: CCB Number: Mailing address: City/State: Zip: Phone: Email: ENGINEER INFORMATION Name: Mailing address: City/State: Zip: Phone: Email: ADDITIONAL INFORMATION Estimatedvalue of workis required(if over$5,000):$ (within the public right-of-way) Is work related to a LAND USE DECISION? E]Yes El No Case number: Cityof Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.dgard-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 15.04.140. * With the exception of a utility operating pursuant to a valid franchise or license with the City of Tigard,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 must sign this application in the space provided or submit a written authorization with this application. Franchised or Licensed Utilities are not required to obtain the owner's signature on the application. I, the applicant, certify that: • To the best of my knowledge,all the information provided within this application package is complete and accurate. • The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject property. • If the application is granted, I will exercise the rights granted in accordance with the terms and subject to all the conditions and limitations of the approval. Linda Ott 5.17.21 Applicant's or authorized agent's signature Print name Date Property owner's signature (if required) Print name Date STAFF USE ONLY Case No: PF12021-00187 Permit fee: Received by: AL Date: 5/24/2021 Approved by: Date: Notified by: Date: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 %k ww.tigard-or.gov • 503-718-2421 • Page 2 of 4 DEVELOPMENT ENGINEERING FEES Public Facility Improvement(PFI)Permit. INITIAL PFI PERMIT FEE Part 1: Required submittal fee is 101/6 of the Net PFI Permit Fee. See below for calculations.Minimum of$300. NET PFI PERMIT FEE Part 2: All non-water system improvements engineer's estimate X 7%(less the initial PFI Permit Fee). WATER LINE CONSTRUCTION FEE Part 3: All public water system improvements engineer's estimate X 12%. FOR ONLY • ' STAFF USE ONLY TYPE 4: SMALL WIRELESS FACILITY TYPE 1-3:DETAILED SUBMITTAL CHECKLIST • Does applicant have a right-of-way license% ❑Yes ❑No TYPE 1 AND TYPE 2-Must include a sketch showing: Under the wireless facilities standards,is the proposal ❑ Dimensions considered?(check all that apply): ❑Small Cell ❑Macro ❑ Street Name How many install sites are proposed as part of this permit ❑ Site Address application? TYPE 3-Must provide 4 sets of plans (sized 24 x 36 or 22 x 34) and an electronic version of all submittal The proposed equipment is located on which of the following: items. The plans must that include: ❑Public Right-of-Way ❑Private Property ❑ Cover—Site,Vicinity,Abbreviation,Legend If equipment is to be located on private property,describe the ❑ General Notes(City,Water,Sewer,etc.) type&use: ❑ Street(Plan,Profile) ❑ Water,Storm and Sanitary (Plan Profile) ❑ Water Quality Facilities ❑ Grading ❑ Landscaping/Tree Plan ❑ Composite Utility Plan(Electrical,Phone,Gas, Storm, Sanitary,Water,Signage,Street Lights,etc.) ❑ Details ❑ Traffic Sight Distance ❑ Signing and Striping ❑ Street Light Plan and Photometric ❑ Engineers seal/signature ❑ Sheet label(project land use name,revision and plan log block,dates and sheet numbers.) ❑ Engineer's Construction Rstimate Additional Submittals (per land use conditions,if applicable) ❑ Traffic Report ❑ Storm water Drainage Calculations ❑ Geotechnical Report ❑ Preliminary Access Report(Sight Distance) ❑ Proposed Plat ❑ Pathway Design ❑ Water Provider Approval Cityof Tigard 13125 SW Hall Blvd. Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 Page 3 of 4 Edge of Pavement FW— Existing Ditch —Streetlight I •—•—•---•—•— —r—•— C House 1 , Existing � Driveway 0. I .I I I rl ° Existing Shop Powe` p I olo la 95' I D grope—CiyLin------------ I Q I Fire Hydrant(FH) I � I TYPE I AND TYPE 2- MINIUM SKETCH REQUIREMENTS (Put N/A if not I I I I I I i I I ' I I � I applicable) North arrow Property lines&dimensions Existing utilities locations (sewer,storm,water) Street&street names All existing structures Proposed work Existing curb or edge of pavement Utility&street light poles Existing S/W or D/W apron Slope of property Trees City of Tigard • 13125 SW Hall Blvd. Tigard,Oregon 97223 • www.tigatd-or.gov • 503-718-2421 • Page 4 of 4 VT73 - - _. :2103A-28 PD 136 .- —� PD 173-��MIPDest VEC2T0314"35 ��' e 5646 PD 138 PD 139 — 9455x9 PI-42 PL430 SW Walnut St SW Walnut St SW Walnut St SW Walnut St SW Walnut St 56 PD I2 – 946G87 C 25 120707 z �' 103A-30 `SPD PD 82 1135y�2 I, PD 1371 � j 1 75 PD 81 12406 11130 I I Better Life `\\ ' • 1 L 3585 Adult Cam Jl436 11100 11070 11030 11000 11 £ 10960 10920 7 i B�17584 • GJoS • RtrT81289 � B 5010138 s 1z>tao n ' 5Z SW EE,,01 St SW Erto15[ SW Enol$t SW 12496 SW Erro1 1110.5 11075 11045 11016 'e 10679 10%6 10949 z 16 10885 0 3 12626 t2341 1 • `� t17864163 C 25 23298 i7C 37--2248' --.25 28223 — _ __ ,z�__ M3027465, M2962482: Crew to work at Pole 3453 to remove overhead service and pull wire through existing conduit to ener ize new meters. 11196 11110 11070 11620 lweo 1L?♦AO CREW NOTES:M3027465:OH to UG Conversion 8 Install 120/240v 200a 1 p UG Service to 2-Pack MeterBase PGE CONSTRUC7/ON DRAWING M2962482:CONVERTING TO 2GANG MB FOR 2 200A 120/240 1P OH SERVS,ADDING ADU _--------- -BU/LT VERIFI Ail Nriacc,,,m— FOaman. Date: Geneal FDaman: Da M: LS'neNn on MNIJ ConiGUMmM a) SOPMbENG REVIEW. JASSOLTBYDESIGNER: DATE SCALE ' NO 5/10/21 WOM3027485 'I'LL Portland General Electric M2962482 ATTENTION: CALL 831 BEFORE YOU OIG CIRCUIT1047 SW Errol Sl Tigard,OR 97223 ssii Y 17 OREGON LAW REQUIRES YOU TO FOLLOW RULES ADOPTED LOCATION By THE OREGON UTILITY NOTIFICATION CENTER. • Cr"to Lw1/ork at Pole 3453 to remove overhead service and U8 WRa THOSE RULES ARE SET FORTH IN OAR 952-001.0010 THINK ICXIStIn conduit to energize THROUGH 952-001-0090 YOU MAYOSTAINCOPIES OF NORPWAY YOVRfNm10:' g new meters. THE RULES BY CALLING THE OREGON UTILITY SAFETY A fflR TRLOCJLRWsSEmNN[s Ra1U[REo rtTORr nR vvxT ` SHEET NOTIFICATION CENTER ADMINISTRATION [N TIE RIOn-0E-wrvwr�aOsa HAWNADE RgOI01 COUNTY SECTIONS L50RNWITH @(sD2-REGOaT1 cam9ACToarHD mmRrcraGvmoluuYRAUE mNm svEa.L Washington C2103A 10F1 TO REQUEST UTILITY LOCATES CALL THE OREGON bow YNxTsbelow. FIRST Af�@MlN15�Nom=TIIE mYAYtx unom �^� T4aalmA M wFEG[N aY mELa aFusolrnwle nAra ouvuron DESIGN aY wrorvE G'+AwN ev UTIL/TY NOTIFICATION CENTER,dal AT LEAST Call before you dig. B9de vnm¢mffml-AosroTll�vERIn MSTaEan STR N uN aswuwrrR Am $Wean 503-612-2935 2 BUS/NESS DAYS PRIOR TO EXCAVATION °"' O PORTIAND GENERA