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PFI2020-00147 1 / 6 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT Request for Permit Action T 1(i,\1t i) 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 ❑X City Staff Check(I)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: ACTION FOR THE ITEM(S) CHECKED (✓): ® CANC /VOID PERMIT APPLICATION. ND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FFFS DUE (attach case fee schedule and provide explanation below). Permit#: PFI2020-00147 Site Address or Parcel#: Project Name: Frontier Subdivision Name: Lot#: EXPLANATION: See attached from applicant. Signature: Oeit " eb Date: 12/10/2020 Print Name: Agnes i or 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 • Not more than 80%of the application or plan review fcc when an application is withdrawn or canceled before review effort has been expended.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 By Route to Records: Date 2/�y/ By Refund Processed: Date 0%//j¢ By Invoice Processed: Date By Permit Canceled: Date 214A? By � Parcel Tag Added: Date By I:\Building\Forms\RegPemvtAction_t O9f8.doc Agnes Lindor From: LoCascio, Lori <lori.locascio@ziply.com> Sent: Thursday, December 10, 2020 1:17 PM To: Agnes Lindor; Trent Brickey Cc: Smith,Julia Subject: PFI2020-00147 Caution! This message was sent from outside your organization. Allow sender I Block sender Hello, Please cancel the permit request PF12020-00147,for Frontier W0857741. Thank you. 5EG3944. 3985.841/!12043 SW Redberry Place new 04/20/2020 P112020-00147 Public Facilities terminal in existing conduit Frontier W0857741 Improvements from MH 4/21 Through HH 65 to HH 576602 for new subdry sign CCr.ir Lee 126A11 CU,{N.. Lori LoCascio OSP Engineering Assistant Oregon Metro- Beaverton 503.469.8363 ZiplyFiber.com� z ix City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 111 Request for Permit Action TIGARD 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 TigardBuildingPertnits@tigard-or.gov FROM: ❑ Owner ® Applicant ❑ Contractor ❑ 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 (✓): • CANCEL/VOID PERMIT APPLICATION. U REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). Permit#: PFI2020-00147 Site Address or Parcel#: Project Name: Subdivision Name: Lot #: EXPLANATION: see attached. Signature: Date: 12/10/2020 Print Name: Lori LoCascio 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 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 OFFICE USE ONLY Route to Sys Admin: Date By Route to Records: Date Refund Processed: Date By Invoice Processed: Date By Permit Canceled: Date By Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_120518.doc Agnes Lindor From: LoCascio, Lori <lori.locascio@ziply.com> Sent: Thursday, December 10, 2020 1:17 PM To: Agnes Lindor;Trent Brickey Cc: Smith,Julia Subject: PFI2020-00147 Caution!This message was sent from outside your organization. Allow sender I Block sender Hello, Please cancel the permit request PFI2020-00147, for Frontier W0857741. Thank you. SEG3944.3985.841//12043 SW Redberry.Place new 04/20/2020 Pr12020-0014 7 Public Facilities terminal in ezisting conduit Frontier W0857741 Improvements horn MU 4/21 Through HH 65 to HI-I 576602 for new subdivision. CCG1t1S//129An CW Ill,* Lori LoCascio OSP Engineering Assistant Oregon Metro - Beaverton 503.469.8363 ZiplyFiber.com ziply 1 RECEIVED Vol b APR202020 Coy City of Tigard P�NNI Go NG NE RING PFI#: 2020-00147 ARD Er ENGINEERING DEPARTMENT TIGARD' Public Facilities Improvement (PFI) Permit PROJECT INFORMATION TYPE OF WORK Project name: W0857741 p TYPE t-PtwtcW Utility Work Brief description of project: PLACE NEW TERMINAL IN EXISTING performed by NWN.Ik7I?, or utility atcnie• CONDUIT FROM MH 4/21 THROUGH HH 65 TO HH 576602 ❑ TYPE z-RUWSidewalk/Ihiveway/Sewer FOR NEW SUBDIVISION Work performed for the purpose of: • Sidewalk installation.or repair • I Mvcway approach installation and repair SITE INFORMATION • Sanitary sewer lateral installation and Location (address if available): 12050 SW 135TH main line tap 0 TYPE 3-Dull Sole Ue.doprucnt Wart performed with hurd use approval which includes any of the holk,win i. • Subdivisions or Partitions APPLICANT'INFORMATION • Srrcetwidening Name: FRONTIER COMMUNICATIONS • Mainline installation for smi tary sewer. storm sewer, 'I•tlard water, and T igrd Mailing address: 4155 SW CEDAR HILLS BLVD .__ water nervier area City/State• BEAVERTON, OR Zip: 97005 0 TYPE 4-Small r kll Tcchtt kogy Phone: 503 644-7153 ❑ TYPE 5-'ligard'rrian*. Email: julia.smith©ftr.com Phone: NOTE: Type I and ?applications rim) la Contact name. DAVE CARNLEY mailed to ptwyknnnvuaw.ud or.W,.. Phone: 971-940-9000 Ems: DAVID.CARNLEY@FTR.COM CONTRACTOR INFORMATION El Same as applicant Name: Ct:B Number Mailing address: City/State: Zip: Phone: ENGINEERINFUI(MA'I RIN Name: Julia Smith Mailing address: 4155 SW CEDAR HILLS BLVDI,ity/State: BEAVERTON, OR Zip: 97005 Phone: 503-644-7153 Email: julia.smith@ftr.eom 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? 0 Ye, 9 No Case number: 9SW • Tigard, 9722 • -);-7 8-2 2 • City of Tigard • 131_5 Hall Blvd. • Oregon . __3 • �cunv.ti#,r:uJ-ucguc • 7t_ I _+_I • Page 1 of 4 APPLICANTS NOTE: Person specified as"Appbe.u,t ,hall be designated"l'ennittee"and shall provide financial assurance fur work,if required by die city pursuant It Ilide. 15.04.140. • Watt flu cucptirm of utility"pouring pW SIWO;to a na&61 francium.:in hentse with the City 11(Tigard,%Own tt,C /Weer and the applicant arc different pent*.die applicant must be the Iwrebaar of record tea lessee in possesairnt with Willa) auth,rirati NI from the nwnc, or an agent ut the owners. Ilre..wi.1.1 must sign the application in the space provided or submit a written authorisation with this apphcafi<n I't.uu hired 01 I.iecnud Utilities are not ny utnvt tot drain thr t nvucr's stgnat arc tut 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. _l. JULIA SMITH 4/17/20 A licant's of authorized agent's signature Print uame Date Property owner's signature (if required) I'rint name Date STAFF USE ONLY Case No: PF12020-99j 47 permit 1ct 3A0- (V Keceived by: SC Late:4/20/2020 Approved by: 7`�!! Date: T!zoIZO2G Notified by: AL Date:112-112,0 City of Tigard • 13125 SW I hall Blvd. • 1 tkard,t hrgttn'J:223 • uwwtiganl-urguv • 503 718-242I • Page 2 of 4 DEVELOPMENT ENGINEERING FEES Public Facility Improvement(PFI)Permit: INITIAL PFI PERMIT FEE Part 1: Required submittal fee is ItP:a of the Net PFI Penny Fee.Sec below for calculations. Minimum of$300. NET PFI PERMIT FEE Part 2: All non-water system unprovements engineer's estimate X 7%(less die initial Nil Permit Fee). WATER LINE CONSTRUCTION FEE Part 3: AU public water system anprovemcots engineer's estimate X 12' FOR STAFF 1,./SE ONLY FOR STAFF USE ONLY TYPE SMALL WIRELESS FACILITY TYPE 1-3:DETAILED SUBMITTAL CHECKLIST REQUIREMENTS Does applicant L.ry a tight-of-way license% ❑Yes 0 Nu fl PL I AND TYPE 2-Must include a sketch showing: Under the wireless facilities standards,is the proposal U Dimensions considered?(check all that apply): 0 Small Cell 0 Macro ❑ Street Name 0 Sue Address How many install sites are proposed as pan of this permit 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 euuipment is located on which of the following: items. The plans must that include: 0 Public Right-of-Way ❑Private Property ❑ t:over—Site,t`iciniry,Abbreviation.Legend If equipment is t'be located on private property,describe the 0 General Notes(City,Water,Sewer,ere.) type&use: ElStreet(Plan,Profile) ❑ Water,Storm and Sanitary(Plan Profile) ❑ Water Quality Facilities O Grading ❑ Landscaping/Tree Plan ❑ Composite Utility Plan(Electrical,Phone,Gas,Storm, Sanitary,Water,Signage,Street Lights,etc.) ❑ Details ❑ Traffic Sight Distance ❑ Signing and Striping ❑ Siren Light Plan and Photometric LU Engineers seal/signature O Sheet label(project land use name,revision and plan log block,dates and sheet numbers.) ❑ Engineer's Construction Estimate Addirioual Submittals (pet land use conditions,if applicable) ❑ Traf&Report ❑ Storm water Drainage Calculations ❑ Geotechnical Report ❑ Preliminary Access Report(Sight Distance) ❑ Proposed Plat ❑ Pathway Design ❑ Water Provider Approval • City of Tigard • 13125 SW Ilaaa Blvd. • Tigard.Oregon 97223 • ww'w uyard ot.gov • Fri 1; "'18 212I • Page 3 of 4 , , .. .. 4.1".• -Rs- [lb.!, -----"" ! / , •fr ‘1!, p!...,Vs we, ga 1 1 T—17.77.3£i Ire teriiir— 1 I I I I .> 1 4er, "A L 1 A11.,4 .2i • L..,.....,,A, 1 I :ill f i‘"4-1- I I r 1 ...sa-• I A 4,1ing..11.p i 1 i I. `N.N. i I iI I I i I i I i I TYPE 1 AND TYPE 2: MINIUM SKETCH REQUIREMENTS(Put N/A if not ap licable) North arrow Property hoe,.i's illinensions I ixisting utilities locations (sewer,storm,water) Street&street names 111 existing structures Proposed work Existing curb or edge of pavement Utility&street light poles Existing S/W or 1)1W apron Slope of property Trees City of Tiganl • 13125 S\\ I WI Blvd. • Tigard,Oregon )7225 • www!ward-m.14(n • Sill '1S-242 I • Page 4 of 9 . PLACE 500' 12F TERMINAL TAIL FROM 51352-5255509-15 1 MH 4/211THROUGH HH 5 TO NEW HH W0857741 57602 BLMT-PROGRESS LANDING SUBDIVISION 2. SPLICE IN MH 4/21 TO H2003, 217-228 SW 135TH AVE &SW REDBERRY CT SIFT INQUIRY 1979939 11999 SW Redberry Ct FRONTIER CONTACT INFORMATION ENGINEERING MANAGER:JOE VANDECOEVERING 503-526-3270 ti NETWORK ENGINEER:JULIA SMITH 503-644-7153 ' onii er CONSTRUCTION MANAGER:DAVE CARNLEY 971-940-9000 Gnmmum[aLDnc CONSTRUCTION COORDINATOR:RON HAYHURST-503-292-3345 BLMT-NEW SUBDIVISION FACILITIES TECHNICIAN:ANGELA ECHAURI 503-643-0390 12050 SW 135TH AVE OPCEN SCHEDULER:RYAN ROBERTS 503-643-3713 Z.' 741 cRuen u2"T" MANNATE ENGR JULIA SMITH GNEY:WASNHGTDN 4/I1120 PHONE 43-614]ISlFILE ECILE.IapJ TM DISTRICT N 1 Di 3 EvmbP: RNG. SEC SEC. 1 nl � ` IIIlijiik I���ENE_ II�n i , El in I ,, ----..,,,,,..1p, �I III •�II 1 Ifittl G ? ' 1 ,� II is vrn PIGTAIL Mill 1`r III . aC .,,:: �4 1 1111\_ i, In q Ai or r PLACE 1500' 12F TERMINAL TAIL II III .: ,/ f 1 I III ���` �1� 111 E ' FROM MH 4/21 TO HH AND THEN IIII zB EN'. I INTO NEW SUBDIVISION Ir� ' I" i. jNI III I ,,.., r $.i! 1I!4/S11 i onie rDma7tmITT! ` BLi 0 E S WJw4s eUz VSV'sO � Al-IL uW0857741 wc rMIN■��� 1 1/ '�---- J� � :: aHraO .T.;Se -I�`_ sz ^ i^ �� ...' r I'M , (T,.7) - I Pi ) 1 JC,141 2..- D _ t71 , D ,) ,..., 0-•t 4/ 0 -' 7. T 5 E•- ;!.. 1..- A - ..' '—) (i , -..... (...) ,:,) r..-, CO —.... J ..) '....(i.......,) .. ,c- 401 41C•a,3 ''''''...., ,—) u.•Ls ontier PLACE 1500' 12F TERMINAL ,.orn rntin.ratinn, BLMT NEW SUBDIVISION TAIL SPLICE TO H2003,217-228 I 1-1'1 I I 12050 SVV 135TH AVE L'ZEIV W0857741 1.;2w.TonEP'':-3.5.2".' 0004,1 DAM PHOR JULIA SMIN tnil,WAtki NGTON 4/1120 PHONE 543 807153 FILE SOME:04100 TM DISTRICT: DING 3 OF 3 WeiSHP HMO SEC 2J1I Ed;min F'eyct Stationary Lane Closure with Flagging Diagram 320 y w a) 4 $ I t n 10 j ul 0 a, • I __ I i• NC I Si O e I • ��` o�� * "R •� � 8o •• "+54t & e!In 1 • .--. r le •_I 3 lb • 1 G • 1 m N0a I al Npv J II mm 1 Qpn 01"' I IY; (s 1 �w2 in j t �Y�l l�J/C .�. 1 g� I m Sims Sp'ini and BWtel 1,g10Ju Ilooml p• •• Span,Se peen Slmns 'Dalai !• g p ts O Ip.d A I C Spar. (,JI! m SO • iu Z p 11 I® 0 IW JS _ 0 < o No 10 100 33 150 350 JSO i130 1 45 110 00 0 I 50 500 500 S00 MO 55 550 •0 1.5 65 700 700 IO 525 A 365 September 2016 Chaplet 5