PFI2021-00095 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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 Fag: 503-598-1960 TigardBuildingPermits@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 (✓):
❑x 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#: PF12021-00095
Site Address or Parcel #: SEG 1729
Project Name: NW Natural
Subdivision Name: Lot#:
EXPLANATION: WA County jurisdiction, no permit require from City of Tigard.
Signature: Date: 3/16/2021
Print Name: Agnes Lindor
Refund Poh
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date B Route to Records: Date 6 Z B
Refund Processed: Date g By Invoice Processed: Date B
Permit Canceled: Date R By Parcel Ta ridded: Date B
I:\Building\Forms\RegPem itAction_ 51 .doc
p City of Tigard PFI#: 2021-00095
ENGINEERING DEPARTMENT
Public Facilities Improvement (PFI) Permit
PROJECT INFORMATION
TYPE OF WORK
Project name: WOO: 3645215 r TYPE 1-Franchise Utility Work
Brief description of project:
Abandon service to: 15345 SW Bull Mountain Rd. performed by NWN,PGE, or utility
agency i
Main is on the 15'in ROW. One 4'x 5'hard surface cut needed. See attached r- TYPE 2-ROW Sidewalk/Driveway/sewer
for details. SEG 1729 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): 15345 SW Bull Mountain Rd main line tap
F- 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: NW Natural/Shelly Kirschenman • Mainline installation for sanitary sewer,
storm sewer, Tigard water, and Tigard
Mailing address: 250 SW Taylor St water service area
City/State: Portland OR zip: 97204 r TYPE 4-Small Cell Technology
Phone:
971-979-6054 F TYPE 5-Tigard Triangle
Email: smk@nwnatural.com Phone: NOTE: Type 1 and 2 applications may be
Shell Kirsehenman emailed to rowpermits(n t c
rd-oeov.
Contact name: Y
Phone: Email:
CONTRACTOR INFORMATION C Same as applicant
Name: Loy Clark/Jade Leedy CCB Number: 52281
Mailing address: PO Box 1369 City/State: Tualatin, OR zip: 97062
Phone: 971-806-2841 Ems: Jade.Leedy@loyclark.com
ENGINEER INFORMATION
Name: Richard Girard
Mailing address: 250 SW Taylor St City/State: Portland, OR Gip: 97204
Phone: 360-921-0314 Email; 12g@nwnatural.com
ADDITIONAL INFORMATION
Estimated value of work is required(if over$5,000):$ (within the public right-of-way)
Is work related to a LAND USE DECISION? C Yes -No Case number:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 1 of 4
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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.
M" ItME -�— Shelly Kirschenman for NW Natural 03/11/2020
Applicant's or authorized agent's signature Print name Date
Property owner's signature (if required) Print name Date
STAFF USE ONTX
Case No: PF12021-00095 Permit fee: Received by: NT Date: 3111/2021
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 101/a 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).
WATERLINE CONSTRUCTION FEE
Part 3: All public water system improvements engineer's estimate X 12%.
FOR ONLY •
NLY
TYPE 4: SNIALL WIRELESS FACILITY TYPE 1-3:DETAILED SUBMITTAL
CHECKLIST REQUIREMENTS
Does applicant have a right-of-way license? I Yes No TYPE 1 AND TYPE 2-Must include a sketch
showing:
Under the wireless facilities standards,is the proposal C Dimensions
considered?(check all that apply): I Small Cell Macro F' Street Name
How many install sites are proposed as part of this permitC 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:
i Public Right-of-Way Private Property
L Cover—Site,Vicinity,Abbreviation,Legend
If equipment is to be located on private property,describe the L General Notes(City,Water,Sewer,etc.)
type&use: L Street(Plan,Profile)
E Water,Storm and Sanitary (Plan Profile)
L Water Quality Facilities
L Grading
L Landscaping/Tree Plan
C Composite Utility Plan(Electrical,Phone,Gas, Storm,
Sanitary,Water,Signage,Street Lights,etc.)
C Details
C Traffic Sight Distance
C Signing and Striping
C Street Light Plan and Photometric
I— Engineers seal/signature
F' Sheet label(project land use name,revision and plan
log block,dates and sheet numbers.)
C Engineer's Construction Estimate
Additional Submittals
(per land use conditions,if applicable)
C Traffic Report
C Storm water Drainage Calculations
C Geotechnical Report
L Preliminary Access Report(Sight Distance)
C Proposed Plat
C Pathway Design
C Water Provider Approval
City of Tigard 13125 SW Hall Blvd. Tigard,Oregon 97223 • www.tigard-orgov • 503-718-2421 • Page3 of 4
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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.tigard-or.gov • 503-718-2421 • Page 4 of 4
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®2021 imagery 0202__Maxar Technologies,Metro,Portland Oregon,State of Oregon,U.S.Geological Survey
Cut: 15345 SW Bull Mountain Rd WO 3645215
1-045-014, REGION 4S NW Natural
TIGARD/PORTLAND,WASHINGTON COUNTY 15031226 4211
T025 R01 W 8NE Proprietary 8 Confidential
Thd document may not be reprodua
Submitted by Kirschenman,Shelly Thu Mar 11 202109:20:02 AM ordotributed without crier written
pennsson from NW Natural.
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Page 84 2011 Edition
Stationary Lane Closure with Flagging Diagram 320
Diagram 320 covers total closure of one lane of a two-lane, two-way
roadway. See the detail inset for the layout if using a single flagger to control
both directions of traffic on low volume roads (less than 400 ADT)with good
sight distance as discussed below.
1. Use truck-mounted flashing warning lights on work and protection
vehicles. See Section 4.3 —Lights and Lighted Signs for exceptions.
2. For added visibility, a truck-mounted arrow board or PCMS in caution
mode may be used.
3. Flaggers at each approach are required if any of the following
conditions exist:
a. Night Operations.
b. Work space is over 200 feet in length.
c. Sight distance is less than 750 feet from each approach
through the lane closure.
d. Traffic volumes are greater than 400 ADT.
4. The length between the Flagger Ahead signs shall not exceed one
mile. Use Diagram 340—Lane Closure with Pilot Car if exceeding one
mile.
5. Cones should be used to outline the work space when curves or other
roadway alignments prevent clear direction for the motorists to pass
the work space safely.
6. Cones along the work space are recommended when posted speeds
are 45 mph or greater, when working under heavy traffic or when travel
lanes are narrower than 11 feet.
7. Extended queue signing (see Diagram 5-4) should be used when
traffic queues extend beyond the initial advance warning sign.
8. When flagging near an intersection,the"Flagger Ahead" (CW23-2)
sign should be visible to traffic entering from any side road. Additional
advance warning and Flagger Ahead symbol signs may be placed on
the side road(s).
9. Sign set-up and flagger placement shown may be used for intermittent
full road closures of 20 minutes or less.
10. The "ONE LANE ROAD AHEAD" (W20-4)sign is optional and should
be considered on high volume or high speed roads, or when extended
queues are expected.
Chapter 5 September 2016