PFI2020-00024 RECEIVED
City Of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT JAN 2 8 2020
Cm Request for Permit Action CITY OF TIGARD
PLANNING/ENGINEERIN
C
13125 SW Hall Blvd. • Tigard,Oregon 97223 . 503-718-2439 • www.dgard-or.gov
d-or.gov
TO: CITY OF TIGARD A t R
Building Division �"
13125 SW Hall Blvd.,Tigard,OR 97223 3/%/Zo
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPertnits@dgard-or.gov
FROM: /owner ❑ Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (BusmessorIndividual) NW Natural
Mailing Address: 220 NW 2nd Ave
City/State/Zip: Portland OR 97209
Phone No.: 503-226-4211
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#: �F Y-U 211.Q(Ji)Z,`'r
Site Address or Parcel#: 14529 SW 72nd Ave
Project Name: WQ #-10 o g 6
Subdivision Name: Lot #:
EXPLANATION: Pre-checker determined work in ROW not necessary. We can
address the required maintenance inside property at the gas riser.
Signature: f an......n Date: 01/28/2020
Print Name: Jamison Forge
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• Not more than 809/6 of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 809/6 of the application or permit fee for issued permits prior to any inspection requests.
Z All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 311 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to Sys Admin: Date Bc Route to Records: Date 3 /� B
Refund Processed: Date ^/ B Invoice Processed: Date B
Permit Canceled: Date 3 / 2D B Parcel Ta Added: Date B
I:\Building\Forms\RegPemvtA ction_M518.doc
RECEIVED V I %
JAN 21 2020 -z�r`r�
. Cry of Tigard CITY OF TIGARD PFI#1-024' Ga,
■ ENGINEERING DEPARTMENI�NNING/ENGINEERING
Public Facilities Improvement (PFI) Permit
PROJECT INFORMATION
TYPE OF WORK
Project name: WO#3600967 r- TYPE 1—Franchise Utility Work
Brief description of project: Replace service and bring up to current standards performed by NWN,PGE, or utility
icy
due to corrosion. 1 standard T-cut required at main connection, bore longside r TYPE 2—ROW Sidewalk/Driveway/Sewer
Into property. Work performed for the purpose of:
• Sidewalk installation or repair
• Driveway approach installation and repair
SITE INFORMATION • Sanitary sewer lateral installation and
14529 SW 72nd Ave, service is located main line rap
Location (address if available): I TYPE 3—Full Scale Development Work
of off SW Bonita Rd y ' �^ performed with land use approval which
includes any of the following.
• Subdivisions or Partitions
APPLICANT INFORMATION • Streetwidening
Name: Jamison Forge NW Natural • Mainline installation for sanitary scwcr,
storm sewer, Tigard water, and Tigard
Mailing address: 220 NW 2nd Ave water service area
City/State:
Portland OR Zip: 97209 r- TYPE 4—Small Cell Technology
Phone:
503-226-4211 x4542 F TYPE 5—Tigard Triangle
Email: Jamison.Forge@NWNatural.com Phone: 503-226-4211 x4542 NOTE: Type I and 2 applications may be
Y
Contact name:
Jordan Lill cY ailed to rowpemuts(&,Ward-orgov.
Phone: 503-226-4211 x4543 F.,il: JYL@NWNatural.com
CONTRACTOR INFORMATION C Same as applicant
Name: CCB Number:
Mailing address: City/State: Zip:
Phone: Entail:
ENGINEER INFORMATION
Name:
Mailing address: City/State: Zip:
Phone: Email:
ADDITIONAL INFORMATION
Estimatedvalue of workis required(if over$5,000):$ (within the public right-of-wap)
Is work related to a LAND USE DECISION? C Yes -No Case number:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 ww-w tigard-ongov 503-718-2421 • Puge 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 owners 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.
Forge, Jamison L: K�-: , Jamison Forge 01/20/2020
Applicant's or authorized agent's signature Print name Date
Property owner's signature (if required) Print name Date
STAFF USE ONLY
Case No: Permit fee: Received by: 140�- Date: ;
Approved by: Date: Notified by: Datc:
City of Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-ocgov • 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 ONLI
TYPE 4: SMALL 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 L Dimensions
considered?(check all that apply): Small Cell i Macro [ Street Name
How many install sites are proposed as part of this permit C 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 I 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)
L Water,Storm and Sanitary(Plan Profile)
L. Water Quality Facilities
L Grading
L Landscaping/Tree Plan
L Composite Utility Plan(Electrical,Phone,Gas, Storm,
Sanitary,Water,Signage,Street Lights,etc.)
[ Details
[ Traffic Sight Distance
L Signing and Striping
[ 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.)
[ Engineers Construction Estimate
Additional Submittals
(per land use conditions,if applicable)
E Traffic Report
[ Storm water Drainage Calculations
L. Geotechnical Report
L Preliminary Access Report(Sight Distance)
L Proposed Plat
[ Pathway Design
E Water Provider Approval
City of Tigard 13125 SW Hall Blvd. Tigard,Oregon 97223 • www..tigard-or.gov • 503-718-2421 • Page 3 of 4
sw "y" St
Edge of Pavement
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1 TYPE 2:
MINIUM SKETCH REQUIREMENTS (Put N/A if not applicable)
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. 9 Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 4 of 4
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NW Natural PLAT: 1-045-022 COUNTY: WASHINGTON Q 01/20/20 07:
(503)226-4211 TOWNSHIP:T02S RANGE: R01W SECTION: 12NE SCALE: 1 IN= 100 FT LMMK)-Js
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.
Id. 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 December 2011
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