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PFI2021-00096
0 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 6P1 C, Request for Permit Action 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.lrov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard, OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPertnits@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#: PF12021-00096 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: &T8,L (K&&Le 1fb Date: 3/16/2021 Print Name: Agnes Lindor Refund PQh 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 TB Route to Records: Date BRefund Processed: Date Invoice Processed: Date BPermit Canceled: Date " Parcel Tag Added: Date B I:\Building\Forms\RegPemutAefim-12051 .doc RECEIVEf city of T `i a, " /� ,4d � PFI#: .2,62L' oe)096 z ENGINEERING DEPARTMENT MAR i 2021 Public, Facilities ImOWnt (PFI) Permit PROJECT INFORMATION TYPE OF WORK Project name: WO#: 3645219 F TYPE 1-Franchise utility Work Brief description of project: Abandon service to: 15395 SW Bull Mountain Rd. Performed by NWN,PGE, or utility agency Main is on the 15' in ROW. One 4'x 5' hard surface cut needed. See attached i TYPE 2-ROW Sidewalk/Driveway/Sewer for details. Work performed for the purpose of: Sidewalk installation or repair Driveway approach installation and repair SITE INFORMATION a Sanitary sewer lateral installation and Location (address if available): 15395 SW Bull Mountain Rd main line tap I— TYPE 3—Full Scale Development Work performed with land use approval which includes any of the following: Subdivisions or Partitions APPLICANT I)< FORMATION a Street widening Name: NW Naturai/Shelly Kirschenman a Mainline installation for sanitary sewer, storm sewer, Tigard water, and Tigard Mailing address: -'50 SW Taylor St water service area City/State: Portland OR Zip: 97204 f- TYPE 4-Small Cell Technology Phone: 971-979-6054F TYPE 5—Tigard Triangle Email: smk@nwnatural.com Phone: NOTE: Type 1 and 2 applications may be emailed to royMermitsn_tigard-or. ov. Contact name: Shelly Kirschenman Phone: Email: CONTRACTOR INFORMATION E 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 Email: Jade.Leedy@loyclark.com ENGINEER INFORMATION Name: Richard Girard Mailing address: 250 SW Taylor St City/State: Portland, OR Zip: 97204 Phone: 360-921-0314 Email: r2g@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? --Yes - No Case number: Cityof Tigard a 13125 SW Hall Blvd. a Tigatd,Oregon 97223 a wwwdgard-or.gov e 503-718-2421 e 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. 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 STATF USE ONLY Case No: �� Permit fec: Received by: Date: Approved by: Date: Notified by: Date: Cityof Tigard • 13125 SW Hall Blvd. • Tigard, Oregon 97223 • www.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/o 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 initialPFI 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 1-3:DETAILED SUBMITTAL CHECELIST 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 L Dimensions considered?(check all that apply): Small Cell \Licro F— Street Name How many install sites are proposed as part of this permit C Site Address applications 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 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) C Water,Storm and Sanitary (Plan Profilc) L, Water Quality Facilities L Grading L Landscaping/Tree Plan L Composite Utility Plan(Electrical,Phone,Gas, Storm, Sanitary,Water,Signage,Street Lights,etc.) L Details C Traffic Sight Distance L Signing and Striping C Street Light Plan and Photometric F- Engineers seal/signature F' Sheet label(project land use name,revision and plan log block,dates and sheet numbers.) C Engineers 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) L Proposed Plat C Pathway Design L 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 Ditch Streetlight 1 -----'—•—.—.— —r—.— ,� I I I i T'�ro'p'os d'Selw'erTire" � Drum e Ni Existing House , a1 I Existing �� Q I ar • Driveway I al I � � � �I �I 1 v;; fl 1 1 W° i °I Existing Shop i Powerpole I I o l �y a 1 95` D Proper- Line-----.z.— O1 Fire Hydrant(FH) I � 1 Scale: I"=30' � I I TYPE 1 AND TYPE 2: MINIUM SKETCH I I 1 ' I I � 1 • not 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 • www.tigard-or.gov • 503-718-2421 • Page 4 of 4 16 � 014180 N 014217 5565 �g \Q\ r� 306' 3 290' _ ut/abandon service to: " 1+ #1424615395 SW Bull Mountain Rd '154)304 4�5�5 S 155TH T °�� `.g O#: 3645219 216' ,eI (w)2 10 'P0� --- 1 1'(P) 014262 r \� � 152 2' 1 4�9 y 7Y .4F 119' d a0 RM' 5' 6-1111-1%'63 ' � i b e_ yyp 5\ S. 61111,2''65 13 b --- (K 76' 10' y � J #15522 87' P SW BULL M UN All 00_�1u #151 P �iV1 p rnviB3 a 14 (w) 15020 � 014901.___ 10' w m„ ,37 g_ /y0 Simds (P) m #14415 (lA/�AIN l7 r5 _ (07) (caut) LLJ > #„466 € ' 2 ” �' 17 a' •- (CPUf) 12 Z g 81'g14429 134' — 116' #14424 0 b 2[ (w) a'c 3 (07) _ (07) 16 117. h N 6 7 #14{43 { #14440 (CPU7f #15555 a (07) 715 4 M _-_ $31' #15550a i4' Cn Iw) 57 #14159 (% (p�.._..- 14455 1 NW Natural PLAT: 1-045-014 COUNTY: WASHINGTON Q 03/09/21 13:0 15031226-4211 TOWNSHIP: T02S RANGE: R01W SECTION: 8NE SCALE: 1 IN = 100 FT 115ER 10-d4h +„ rr Z ., � 1. .. t .1r r � �` •�, �!, �Y •, g f to .�! nF.n , 1 T1�,� r .,/,]� IL _.al . �1 ti Cut/abandon service to: f moi - 15395 SW Bull Mountain Rd LT It 1 I L• 1 r ft Y• � • � r Nrfy� ,r4 s i ap data©20211 Imagery 02021 ,Maxar Technologies,Metro,Portland Oregon,State of Oregon,U.S.Geological Surveys Cut; 15345 SW Bull Mountain Rd WO 3645215 �� NW Natural 1-045-014, REGION TIGARD/PORTLAND, WASHINGTON COUNTY (5031226-4211 T02S R01 W 8N E Proprietary& Confidential 'his document may not be reproduced Submitted by Kirschenman, Shelly Thu Mar 11 2021 09:20:02 AM or distributed without prior written permission from MN Natural. - Cl) Single Flagg Operationm . (Optional) o N a a = for Low Volumes N `�1f�J m (ADT<400) �° O BE 91 � n e e c PREPARED ONROAD LANE H 4e b Ie 1 TO STOPAHEAD A — — —• • ma — — ROAD 8 8 75 S m ♦ \ / V=VVORK n n o KcKeKeK� I--I �� emw O (n � <11 • A B B — -------- - -------------1 1 aIle _ f max. !v C4 K K ot B K Barer % \ Protection Vehicle w/TMA(both Optional) ROAD See Chapter 4 0 WORK pi AHEAD // BE L•Q ONE LA PREPARED TWo Flagger Operation " AHEAD .TO STOP W m m N00 (Optional) o Ch e 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