PFI2019-00266 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT At
Request for Permit Action
T I G A R p 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • ww-w.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 ® City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Busincssorindividuan Brett Sherwood, Frontier Communications
Mailing Address: 4155 SW Cedar Hills Blvd
City/State/Zip: Beaverton, OR 97005
Phone No.: 503-578-9014
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
a VOID PERMIT APPLICATION.
111 • i PERMIT FEES (attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: PF12019-00266
i Site Address or Parcel#: Adjacent to 13615 SW 124th Av.
Project Name: Bore parallel to ROW to service new customer.
Subdivision Name: N/A Lot#: N/A
EXPLANATION: Permit has been inactive since 8/15/2019. Fee has not
been paid by applicant.
Signature: r Date: 12/16/2020
Print Name: Jeremy Tamargo
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 2. ( re., By,�f
Refund Processed: Date N/A' BB OP Invoice Processed: Date By
Permit Canceled: Date 'L/ / -, By /9 Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1 05 doc
RECEIVED
City of Tigard Mc. IAUG 15 2019 PFI#:�ol�— OG�2(.¢
ENGINEERING DEPARTMENT
ITY OF TIGARD
Public Facilities ffient (PFI) Permit
PROJECT INFOORMATI,O�N (� TYPE OF WORK
Project name: ( l0/5 7"," I2Y r6GI'}z 'F�rI'►'t(f /TYPE 1-Franchise Utility Work
Brief description of project: 13Ot.. fawa(ta l 4 performed by N1\'N,PGE, or utility
agency
.60W +0 'Qxv 1 CrL ZiA.) CLk +t Y Q-t ❑ TYPE 2-ROW Sidewalk/Driveway/Sewer
Work performed for the purpose of
• Sidewalk installation or repair
• Driveway approach installation and repair
SITE INFORMATION • Sanitary sewer lateral installation and
( available): SW I2Y- - main line tap
Location address if available
�� performed❑ TYPE 3-Full Scale DevelopmentWork
with land use approval which
includes any of the following:
• Subdivisions or Partitions
APPLICANT INFORMATION • Street widening
Name:
✓Ok 'h ex Cern m► m C0.-hOr'is • Mainline installation for sanitary sewer,
/ r storm sewer, Tigard water, and Tigard
r,
Mailing address: 1 (5 6 S(A) ( I-tills 13 I lie water service area
'(�Qrtvc f OIL 76 O 5 ❑ TYPE 4-Small Cell Technology
City/State: D p: q !
Phone:
03 — I S-78 ''10/Y 0 TYPE S-'I'iF,ard'I'rianKle
Email: Phone: NOTE: Type 1 and 2 applications may be
(7 ra4 f- /' „`aO� mailed to r'wpezmio';y;ji..}arti or Win..
Contact name: �1�✓� -t+� G;�j u W /_���
Phone: J0�J, �g — [o1 1 Email: C -Ct.+�00 'P4T ce,vn
CONTRACTOR INFORMATION ❑ Same as applicant
Name: SC)�1 GOV1' Consf raoh` CCB Number: I gS I I rD
Mailing address: ( 2-1 S 6t «F— Clf; City/State: Corrut.1l LAS/01g- Zip: c )7((5
Phone: 60. ' 'R '3`1KS Email: pj'tIZ(10W06OV11COW.C.o('r.Cprn
ENGINEER INFORMATION
�rpp
Name: Ttl te4Z-1/ �644
_J (� I p _ ,� I_ p
Mailing address: . ��s SW O c ' `I(`SCity/State:`-(/-t a''D`/O I�ZiipL: e ! oo s
Phone: 6O 3 -S-7 g — / 0 1 Email: b th •S W00010.'['I T• Gdfl'l
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 Yes tit No Case number:
City of Tigard • 13125 S\X'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
arc 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 arc 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.
Sew 00o4 27(5il
Applicant's or authorized agent's signature Print name Date
Property owner's signature (if required) Print name Date
STAFF USE ONLY
Case No: Q(p Permit fee: Received by: k.S Date: B I S 19
Approved by: T/'rL/7/ Date: 8//9'I/9 Notified by: P" Date: ' 'I°(
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 2 of 4
/
NOT A MAJOR STREET.
OREGON TCP 300, SHOULDER
WORK WITH MINIMAL ROAD
,per ENCROACHMENT ATTACHED.
ti9),
ylip,
"9y
CONTACTS:
13595 I OSP Const:PJ Fellows 503-519-3445
92' OSP Engineer:Brett Sherwood 503-578-9014
BORE ALONG Facil Tech:Laurel Kielty 425-263-4006
ROW THEN INTO OSP Inspct:Ron Hayhurst 503-292-3345
PRVT PROP.
13615 SW 124TH AK
LOOKING NORTH
CA
ROW 42' R
I8' I 1.3'
(OR EON
SW TALON LN I'
\ w ''"NEW CONDUIT
= OW 111MP=rau Rn
I fronTier
l -* ��,���ro� p,m'' Q Communications
s wWww MA.mea it 13815PER8W 124TH AVE
1"- 1 WING
�p�.n�s""'" . non�w 4i,'e'Ems. PNOIECT BULL MIN
,.WrN wW-v m,W V 49 M.N.•R NUMBER. 51 I
WOOF RATE: ENOR9 SHE Nfl HING TCNi
&15/19 PHONE.503-575-901 OILE.
SCMF:1.100 TA%BISTRICO. WG 1 Or I
TWNSHP' RNG. SEC.
Page 80 2011 Edition
5.3 Two-Lane, Two-Way Roads
Shoulder Work w/ Minor Road Encroachment Diag. 300
Use this detail for non-freeway work which extends into a travel lane and
maintains a minimum 10 foot travel lane. If a minimum 10 foot travel lane
can not be maintained, or when traffic can not safely pass by in both lanes
simultaneously, use the appropriate lane closure diagrams—for example,
Diagrams 310 through 350.
A lane closure may be appropriate for conditions such as high traffic
volumes, high speeds, and inadequate approach sight distance to the work
space, or heavy equipment adjacent to the travel lane.
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. Cones shall be placed along the entire length of the work space. If a
protection vehicle is used and work is in place one hour or less,the
taper and tangent devices may be omitted.
4. If the speed is 45 mph or higher, volumes exceed 2000 ADT, or there
is limited sight distance, consider placing cones or tubular markers on
centerline.
5. An arrow board in caution mode or truck-mounted PCMS with
"SHOULDER WORK"or other appropriate message may be used for
higher visibility.
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
40 350 350 350 150
45 180
50 500 500 500 210
55 250
Chapter 5 December 2011
2011 Edition Page 81
Shoulder Work wl Minor Road Encroachment Diag. 300
ROAD
WORK TA
•
AHEAD
•
Initial
Warning A •
Sign rl
•
•
(Optional) •
• •
• 1/ll
•
In
Protection n
w/TMA(both
h Optional)
See Chapter 4 • Buffer
•
10' •
minimum • Usj
•
A j ROAD\
NARROWS
(Optional)
B
1 1
1 WORK
AHEAD
Initial
Warning
Sign
December 2011 Chapter 5