PFI2021-00205 t
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTa'i �/ � 4-d= Request for Permit Action d
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 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ® Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business orIndividu4 J5 Infrastructure Partners
Mailing Address: 6732 SW Terri Ct
City/State/Zip: Portland, OR 97225
Phone No.: 503-312-3400
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#: PF12021-00205
Site Address or Parcel#: 15862 SW Upper Boones Ferry Rd,Tigard, OR 97224
Project Name: TGARD_010
Subdivision Name: Lot#: 2S112DD-00200
EXPLANATION: Pole is PGE owned metal streetlight, PGE does not currently have resolved
design standards.
Si nature: /'( Date: 07/26/2021
g
Print Name: K4eredith T.M. Hewett
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund ofi
• 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 • ONLY
Route to S s Admin: Date By Route to Records: 7 Date � B
Refund Processed: Date I By 4F d9 1 Invoice Processed: I Date B
Permit Canceled: Date 9 B Parcel T Added: Date B
1:\Building\Forms\RegPermitAction_1 o51 .doc
City of Tigard V
Ti 0 1 e6 Pl 1 PF12021-00205
#:
ENGINEERING DEPARTMENT r'��- e,;,
• . Public Facilities Improvement (PFI) Permit
PROJECT INFORMATION TYPE OF WORK
Project name: TGARD_010 / 16448-010A
❑ TYPE 1—Franchise Utility Work
Brief description of project Placement of Small Wireless Facility performed byNWN,PGE, or utility
agency
entirely contained within a city light pole ❑ TYPE 2-ROW Sidewalk/Driveway/Sewer
SEG 2365 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): Adjacent parcel 15862 SW Upper main line tap
❑ TYPE 3—Full Scale Development Work
Boones Ferry Rd, on the NW side of SW Upper Boones Ferry Rd performed with land use approval which
includes any of the following:
• Subdivisions or partitions
APPLICANT INFORMATION • Streetwidening
Name:New Cingular Wireless PCS, LCC D/b/a AT&T Wireless, LLC • Mainline installation for sanitary sewer,
storm sewer, Tigard water, and Tigard
Mailing address: 19801 SW 72nd Ave, Suite 200 water service area
City/State: Tualatin, OR Zip: 97062 P1 TYPE 4—Small Cell Technology
Phone: 425-214-2186 U TYPE 5-Tigard Triangle
Email:ko3199(a)att.eom Phone: 425-214-2186 NOTE: Type 1 and 2 applications may be
Contact name:Martha Miller emailed to rowpermits(ntigard-or.gov.
Phone: 510-325-3362 Email: mmiller@j5ip.com
CONTRACTOR INFORMATION ❑ Same as applicant
Name: Capstone Solutions Inc CCB Number: 196584
Mailing address: 13126 NE Airport Way, Suite 100 City/State: Portland, OR Zip: 97230
Phone: 503-707-2656 Email: cblack@capstoneemail.com
ENGINEER INFORMATION
Name: J5 Infrastructure Partners - James Chung
Mailingaddress: 2030 Main St, Suite 200 City/state: Irvine, CA Zip: 92614
Phone: 949-247-7767x111 Email: jchung@j5ip.com
ADDITIONAL INFORMATION
Estimated value of work is required(if over$5,000):$ 18,000.00 (within the public right-of-way)
Is work related to a LAND USE DECISION? ❑Yes ®No Case number:
Cityof Tigard • 13125 SW Hall Blvd. 0 Tigard,Oregon 97223 • www.dprd-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 requind 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.
�✓lG� LL� 7iV&4,
Martha Miller 5/27/2021
Applicant's or authorized agent's signature Print name Date
Property owner's signature (if required) Print name Date
STAFF USE ONLY
Case No: PF12021-00205 Permit fee: Received by: Date: 6/3/2021
Approved by: Date: Notified by: _Date:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 wwwtigard-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 10%of the Net PFI Pen-nit 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 • ONLY
TYPE 4: SMALL WIRELESS FACILITY TYPE I-3: DETAILED SUBMITTAL
CHECKLIST REQUIREMENTS
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 Estimate
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 • wwwtigard-or.gov • 503-718-2421 • Page 3 of 4
Edge of Pavement
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Streetlight 1 A' '�'�'�'�'�' -r —
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'eiopos d"Serwer'CiI –
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Existing House 1
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Power`poleI I
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Fire Hydrant(FH)
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1 TYPE 2:
MINIUM SKETCH REQUIREMENTS 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
Cityof Tigard • 13125 SW Hall Blvd. Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 4 of 4