PFI2020-00158 .� 1 V
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
°� _ " Request for Permit Action
i I u A h n 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 l 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 (1):
MCANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and ro 'de r lanation below).
Permit#: WI 2 20-QD(5 • rprefurr4
Site Address or Parcel#: 6€ 35 3a / 3
Project Name:
Subdivision Name: C ntu lI L(n k. I QWQ&+ Lot#:
EXPLANATION: CIL/Fin OttG of PRW20-cOI(p3
Signature: 'air"_ Date: 6I(P POPrint Name: tVitneS (r.(yl6-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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 Adtnin: _ Date By Route to Records: Date/v q/ B, .1 t'")
Refund Processed: Date N of- By,4QO Invoice Processed: Date By
Permit Canceled: Date/2.J//f zo B 0 Parcel Tag Added: Date By
1:\Building\Forms\RegPemutAction_1 051 .doc
Agnes Lindor
From: Trent Brickey
Sent: Wednesday, May 6, 2020 7:39 AM
To: ROW Permits
Subject: RE: N.558399 -- REVISION REQUEST ON PERMIT APPLICATION -- CENTURYLINK/QWEST
Categories: Misc. Correspondence
created PFI f r Schuyler o those revisions, PFI2020 00163. Can we cancel the PFI2020 00158 since it hasn't been
approved and use the one Schuyler made? Would that be easier for you? Let me know because it doesn't matter to me.
Trent
From: ROW Permits<rowpermits@tigard-or.gov>
Sent:Wednesday, May 6, 2020 7:18 AM
To:Trent Brickey<trentb@tigard-or.gov>
Subject: FW: N.558399-- REVISION REQUEST ON PERMIT APPLICATION --CENTURYLINK/QWEST
Hi Trent-
This is a revision to permit PFI2020-00158,can you please print and attach to the permit that was previously created and
emailed to you. I will swap it out when I get it back from you after you review it.Thanks,
Agnes
From: Permitting<permitting@mountainitd.com>
Sent:Tuesday, May 5, 2020 3:58 PM
To:Trent Brickey<trentb@tigard-or.gov>; ROW Permits<rowpermits@tigard-or.gov>
Cc: Permitting<permitting@mountainitd.com>
Subject: N.558399 -- REVISION REQUEST ON PERMIT APPLICATION --CENTURYLINK/QWEST
Caution!This message was sent from outside your organization. Allow sender I Block sender
Good Evening,
Attached is the revised permit application showing that the construction will be "boring" same distance and not
"trenching".
Please let me know if you need anything else.
Thank you,
Breanna Hodge
Engineer Assistant
PH: (208)576-4031
1
144,4
WM
EXPLORE YOUR POSSIBILITIES.
www.MOUNTAINLTD.com
EOE,AA.
Contracted to:
' CenturyLink•
DISCLAIMER: E-mails sent or received by City of Tigard employees are subject to public record laws. If requested, e-mail
may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law. E-mails are retained
by the City of Tigard in compliance with the Oregon Administrative Rules "City General Records Retention Schedule."
2
‘.. tffi %). 1 u
RECEIVED rr.//rivet,3
City of Tigard MAY 0 2020 PFI#: 2020 00158
• ENGINEERING DEPARTMENT CI�r OF TIGARD
l 1 t, \ l(1, Public Facilities IiafeffffiVti (PFI) Permit
PROJECT INFORMATION
N558399 TYPE OF WORK
.
Project name: ❑ TYPE 1—Franchise Utility Work
Brief description of project: CTL is proposing to trench 519' from existing performed by NWN,PGE, or utility
agency
pole to pole,placing(2) 4" conduit at 36" depth. ❑ TYPE 2—ROW Sidewalk/Driveway/Sewer
Work performed for the purpose of:
• Sidewalk installation or u.Peir
• Driveway approach installation and repair
SITE INFORMATION • Sanitary sewer lateral installation and
10385 SW 87th Ave main line tap
Location (address if available): ❑ TYPE 3—Full Scale Development Work
SEG3530 and SEG3529 performed with land use approval which
includes any of the following.
• Subdivisions or Partitions
APPLICANT INFORMATION • Street widening
Name: CenturyLink/Qwest • Mainline installation for sanitary sewer,
storm sewer, Tigard water, and Tigard
Mailing address: 6074 N Discovery Way Ste.125 water service area
City/State: Boise,ID Zip: 83713 ❑ TYPE 4—Small Cell Technology
Phone:
208 576-4031 ID TYPE 5-Tigard Triangle
permitting@mountainitd.com
Email: Phone: NOTE: Type 1 and 2 applications may be
Contact name:
Breanna Hodge emailed to rowpermits@tigard-or.gov.
Phone: 208-576-4031 Email: permitting@mountainitd.com
CONTRACTOR INFORMATION 0 Same as applicant
Name: Jason Scherf/ Quanta Telecom CCB Number:
Mailing address: 2311 E 1st St. City/State: Vancouver,WA Zip: 98661
Phone: 360-605-6721 Email: jscherf@quantatelcom.com
ENGINEER INFORMATION
Name: Keith Frazier
Mailing address: 4501 NE Minnehaha St Bldg 2 City/State: Vancouver,WA Zip: 98661
Phone: 360 669 3707 Email:
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 IN No Case number:
City of Tigard • 13125 SW Hall Blvd. • 'Tigard, Oregon 97223 • wwurtigard-or.gov • 503-718-2421 • Page I 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.
8restiuta f{oa y Breanna Hodge 05/01/20
Applicant's or authorized agent's signature Print name Date
Property owner's signature (if required) Print name Date
STAFF USE ONLY
Case No: PFI2020-001 58 Permit fee: Received by: SC Date: 5/04l2020
Approved by: Date: Notified by: Date:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-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 PH 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 PH Permit Fee).
WATER LINE CONSTRUCTION FEE
Part 3: All public water system improvements engineer's estimate X 12%.
FOR STAFF USE ONLY FOR STAFF USE ONLY
TYPE 4: SMALL WIRELESS FACILITY TYPE I—3:DETAILED SUBMITTAL
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): 0 Small Cell 0 Macro ❑ Street Name
How many install sites are proposed as partof 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:
0 Public Right-of-Way ❑Private Property
❑ Cover—Site,Vicinity,Abbreviation,Legend
If equipment is to be located on private property,describe the El General Notes(City,Water,Sewer,etc.)
type&use: ❑ Street(Plan,Profile)
❑ Water,Storm and Sanitary(Plan Profile)
❑ Water Quality Fa-ilities
❑ 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.)
❑ Engineer's 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 • wwwtigard-oLgov • 503-718-2421 • Page 3 of 4
Edge of Pavement
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TYPE 1 AND 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
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 4 of 4
CENTURYLINK
CENTURYLINK
N.558399 / DA323631
10385 SW 87TH AVE
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www.invarion.com
Date: 07/02/2020 Author: Jessicah Cole 208-442-0104
Comments:
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