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PFI2021-00257 V0 0 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT / fd ■ Request for Permit Action 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • waW.dord-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuiLdingPernn is@dgard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor ❑Q City Staff Check(V)one REFUND OR Name: INVOICE TO: (Business ofInclMdual) 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#: PF12021-00257 Site Address or Parcel#: SEG 267 Project Name: PGE Subdivision Name: Lot#: EXPLANATION: Duplicate of PF12021-00252. Signature: Date: 7112/2021 Print Name: Agnes Linddr 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. ' OFFICE USE ONLY Route to Sys Admin: Date By Route to Records: I Date 6 ByAeh Refund Processed: Date -B e) Invoice Processed: Date B Permit Canceled: Date By <!t3 Parcel Tag Added: Date B 1:\Building\Forrns\RegPermiWction_t 051 .doc as� ! D. City of Tigard '0d PFI#: PF12021-00257 = ENGINEERING DEPARTMENT Public Facilities Improvement (PFI) Permit PROJECT INFORMATION PGE Job # M2927226 TYPE OF WORK Project name: B TYPE I—Franchise Utility Work Brief description of project: Replace 3 power poles and existing performed by NWN,PGE, or utility agency wire, install 1 new pole ❑ TYPE 2—ROW Sidewalk/Driveway/Suver SEG 267 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): 10255 SW 70TH AVE, Tigard main line tap on 70th between SW Locust ST and SW Oak ST ❑ TYPE3—Full landuscale evapprov l Work performed with land use approval which includes any of the following. • Subdivisions or Partitions APPLICANT INFORMATION • Street widening Name: PGE Briana Fogh/Jacob Halvala • Mainline installation for sanitary sewer, storm sewer, Tigard water, and Tigard Mailing address: 4245 Kale St NE water service area City/State: Salem 'Lip: 97305 ❑ TYPE 4—Small Cell Technology Phone: 503.530.9396 ❑ TYPE 5-Tigard Triangle Email: Bdana.Fogh@pgn.eom Phone: 503.530.9396 NOTE: Type 1 and 2 applications may be Contact name: Jacob Haivala emailed to rmWermits(a tigard-or.gov. Phone: 503.530.9396 Email: jacob.haivala@pgn.eom CONTRACTOR INFORMATION Q Same as applicant Name: CCB Number: Mailing address: City/State: Zip: Phone: Email: ENGINEER INFORMATION Name: Jacob Haivala Mailing address: 4245 Kale St NE City/State: Salem zip: 97305 Phone: 503.530.9396 Email: jacob.haivala@pgn.com ADDITIONAL INFORMATION Estimated value of work is required(if over$5,000):$ (within the public right-of-way) Is work related to a I.AND USE DECISION? []Yes Q No Case number: City of Tigard • 13125 SV'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 15.04.140. * 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 a ith 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. Bdana Fogh 7/1/2021 Applicant's or authorized agent's signature Print name Date Property owner's signature (if required) Print name Date STAFF USE ONL'i PF12021-00257 7/6121 Case No: Permit fee: 300•00 Received by: NT Date: Approved by: Tu7 A k. Date: 7 J 8'/ZO 2/ Notified by:_A Date: -1191= City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.dgard-or.gov • 503-718-2421 Page 2 of 4 DEVELOPMENT ENGINEERING FEES Public Facility Improvement(PFI)Permit: INITIAL PFI PERMIT FEE Pan 1: Required submittal fee is 10%of the Net PFI Permit Fee.See below for calculations.Minimum of$300. NET PFI PERMIT FEE Pan 2: All non-water system improvements engineer's estimate X 7%(less the initial PFI Permit Fee). WATER LINE CONSTRUCTION FEE Pan 3: All public water system improvements engineer's estimate X 12%. FOR ONLY ONLY DETAILED SUBMITTAL TYPE 4: SMALL WIRELESS FACILITY REQUIREMENTS 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.) ❑ Engineers Construction Estimate Additional5ubmittals (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 City of Tigard 13125 SAX/Hall Blvd. Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 3 of 4 Edge of Pavement �— Ditch + 4 a ---r Streetlight ......—•— •—•-r-'- �ITI1S� Ri DmisAq h V) Existing House Existing D 111 >I >� Driveway v� al cca" 1 01 I � Existing Shop I r Powerpole I I d I Ia 95+ O 7iopeity Line— — — — — I I Fire Hydrant(FH) � I Scale: 1"=30' � I I TYPE 1 AND TYPE 2: MINIUM SKETCH 1 � � I � REQUIREMENTS (Put N/A if not applicable) North arrow Property fines&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 Fall Blvd. - Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 4 of 4