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PFI2021-00104 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMEV 0 , Request for Permit Action iA1I'/ 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 TigardBttildingPermits@tigard-or.gov FROM: ❑ Owner X❑ Applicant ❑ Contractor ❑ City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) NW Natural/Aisha Rivers Mailing Address: 250 SW Taylor St City/State/"Lip: Portland. OR 97204 Phone No.: 971-979-6055 PLEASE TAKE ACTION FOR THE ITEMS) 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#: PF12021-00104 Site Address or Parcel#: 15765 SW 80th Ave Project Name: WR#3626156 Subdivision Name: I..ot#: EXPLANATION: The necessaN work come to find out wasn't not NW Natural's Signature: Date: 5/13/21 Print Name: NW Natural isha Rivers 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 fce for issued permits prior to any inspection requests. 2. All refunds will be rctumed 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 OFFICE USE ONLY Route to S s Admin: I Date 13Y Route to Records: Date B Refund Processed: Date 441LB Invoice Processed: Date B Permit Canceled: Date B Parcel Tag Added: Date B L\Building\Forms\Rey Pennic'lction_1.A51 .doe -AEC'EIVED City of Tigard P/0 f 2-( �� MAR 19 2021 �'�"1 #: •'2�'2�" 00/0�-,� ENGINEERING DEPARTMENT Public Facilities I CITY OF TIGARDt (PFI) Permit PROJECT INFORMATION TYPE OF WORK Project name: WR#:1626156 ❑ TYPE 1-Franchise Utility Work performed by NWN,PGE, or utility Brief description of project: Repair leak at svc tee. Main is on the 6' in mac, ROW in grass strip, ❑ TYPE 2—ROWSidewalk/Driveway/Sewer Work performed for the purpose of • Sidewalk installation or repair • Driveway approach installation and repair SITE INFORMATION • Sanitary sewer lateral installation and _ y��� main line tap Location (address if available): 15765 SW 80th Ave •E'.�c'S ❑ TYPE 3—Pull Scale Development Work performed with land use approval which includes any of the following. • Subdivisions or Partitions APPLICANT INFORMATION • Street widening Name: NW Natural • 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 ❑ TYPE 4—Small Cell Technology ❑ TYPE 5—T*ard'1'riangle Phone: 971-979-6055 Email: nwnpermits(a nwnatural.com Phone: 800-882-3377 NOTE: Type 1 and 2 applications may be emailed to rowpermitsQtieard-oveovoveov. Contact name: Aisha Rivers Phone: Email: CONTRACTOR INFORMATION ❑ Same as applicant Name: Loy Clark CCB Number: 52281 Mailing address: PO Box 1369 City/State: Tualatin, OR Zip: 97062 Phone: 971-806-2841 Email:iade feed a lovclark com ENGINEER INFORMATION Name: NW Natural/Rich Girard Mailing address: 220 NW 2nd Ave City/State: Portland, OR Zip: 97209 Phone: (360) 921-0314 Email: r2g(o)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: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.figard-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. A� NW Naturai/Aisha Rivers 3119/21 Applicant's 6k authorized agent's signature Print name Date Property owner's signature (if required) Print name Date STAFF USE ONLY Case No: Permit fee: _100,01 Received by: _ �_,� Date: Z Approved by: ri" Date: Notified by: Date:3 23 ZoZ� City of 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 10%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 WIRELESSTYPE 4: SMALL 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,`trinity,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 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 City of Tigard 13125 SW Hall Blvd. Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 3 of 4 C I Edge of Pavement I Ditch Streetlight — •-----•---•—•—r—•— r a• t EWA%Drat I o.. e o I I ' ' T–�iopos cf•Se1vretTine" I CL) II j al at Existing House �I I Existing at Driveway 3t ail Vt I I /�Dj a l I I o., v 1 t � o ' I Existing Shop j Powerpole I I = C� 7rapeitLme y —-—-—-—-—- AAA I I Fire Hydrant(FH) Scale. 'I-=30' l I I TYPE 1 AND TYPE 2: I I I I I I 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 a 13125 SW Hall Blvd. a Tigard,Oregon 97223 0 wwwtigard-otgov a 503-718-2421 • Page 4 of 4 all 6: (� N mew 7L2�udt 5eeD s. O f �- m s 1°19960 - ,segs , 1w 15°0596189 °e °1 as M 12iT59elriT9 BON 1M6WWRSNINuTON I Ci) TI6 D ——— C q a n i I lr Laee M74 mw §I 8 ♦C ISM : 1 IemOD�pKA NULL M10 ���eee r I 9ow�.Iep 1025 (1115) I P Hage RON, 6auion 13W w @@ m Raft Oparo N ®®� rtbl tltspo y t ,•CWS __—_ __. .IeTM —- TSe I Q' � � S'W. SIMI C URCHIL WAY W j ns*es _ .r •,mee °4nsTys 3 � neem � , ': PA K .-SSL. 73 el I 21RPlee w er0+1 T° a, ° It welmsnsWo y 40 38 T 1e) No a1 tl 1 2 ]s 3 6 ti it FOREST b - .,eeeo C m g g � ,R., W pe) & rn E n g II { € 6 ZIPPY S.W. { I$ I I I +W)M Page 94 2011 Edition Self-Regulating Lane Closure Diagram 350 Use this detail for closures of one lane of a low-speed, two-lane, two-way road. 1. Use this diagram only if all of the following are true: a. Work space is less than 200 feet. b. The posted speed is 40 mph or less (unless not posted and speed governed by basic rule). c. Average Daily Traffic (ADT) is less than 400. d. Sight distance (in feet) is more than 750 at each end. 2. Use truck-mounted flashing warning lights on work and protection vehicles. See Section 4.3 — Lights and Lighted Signs for exceptions. 3. For added visibility, a truck-mounted arrow panel or PCMS in caution mode may be used. 4. A"Lane Ends (Right)" (W4-2R)symbol sign, or"RIGHT LANE ENDS" (W9-1 R) sign, may be placed inside the cone taper for more emphasis. Sign Spacing and Buffer Lengths (feet) Posted Spacing Between Signs "Buffer" Speed A B C Space 20 50 25 100 100 100 75 30 100 35 350 350 350 125 40 150 45 180 50 500 500 500 210 55 250 60 285 65 700 700 700 325 70 365 Chapter 5 September 2016 2011 Edition Page 95 Self-Regulating Lane Closure Diagram 350 ROAD --��j WORK B AHEAD 1 • InRial 14 to Warning • Sign • A • • ONELANE • tROADD • �� Protection Vehicle • Tp wFrMA(both Optional) ONCOMING OR TO See Chapter 4 • TRAFFIC ONCOMING, TRAFFICi I I• Buffer •• 501-100, yORV I5 A ONE LANE B ROAD AHEAD / ROAD 1 WORK AHEAD Initlal AH Warning Sign September 2016 Chapter 5