PFI2019-00334 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENV 0 a
Request for Permit Action co/3�iq- •�
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 TigardBuildingPermits tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
Check(✓)one
W ^ REFUND OR Name:
/'� INVOICE TO: (Business or Ind victual)
Mailing Address:
City/State/Zip:
Phone No.:
[PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
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#: P(PZ Iq'-d(1571
Site Address or Parcel#: Sz,6l79
Project Name: C (A5 . 61- 1L_..( J � 0,‘
Subdivision Name: Lot#:
EXPLANATION: pt,plrt 1'EL Tk ont it 4,41 vse_ t f Fiuot-0691Z. Ifo -WI l •
Signature: � Date: `_a-I
Print Name: SGrt,,,,i f a0
I
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date By Route to Records: Date rip/3 /9. By
Refund Processed: Date N/-� By [ Invoice Processed: Date By
Permit Canceled: Date ye 3✓p9 By Parcel Tag Added: Date By
I:\Building\Forms\RegPenmitAction_1 51 .doc
RECEIVED V
SEP 26 2019 fe/3779
City of Tigard p���AA��NI NG/ENGINEERING TY OF TIGARD
PH#: I FilaiQ—(�i33`�
= ENGINEERING DEPARTh1EIV'I
1 IGARD Public Facilities Improvement (PFI) Permit
PROJECT INFORMATION
61472 Plant Extension TYPE OF WORK
Project name: — 0 TYPE 1—Franchise Utility Work
Aerial overlash between existingperformed by INN,PGE, or utility
Brief description of project:
agency
utility pole on SW 72nd Ave and SW Locust St. o TYPE 2—ROW Swa&/DrjvcwavfScwcx
Work performed for the purpose of:
• Sidewalk installation or repair
• Driveway approach installation and repair
SITE INFORMATION • Sanitary sewer lateral installation and
Location (address if available):
10175 SW 72nd Ave,Tigard, OR 97223 malt line tap
❑ TYPE 3—Full Scale Development Work
l7L1 I performed with land use approval which
includes any of the following:
• Subdivisions or Partitions
APPLICANT INFORMATION • Street widening
Name:
Comcast • Mainline installation for sanitary sewer,
storm sewer, Tigard water, and Tigard
Mailing address: 11308 SW 68th Parkway ice area
City/State: Tigard, OR Zip: 97223 0 TYPE 4—Small Cell Tecluiology
Phone:
(971) 801-5787 0 TYPE 5—Tigard Triangle
Email: Van_Mesplay@comcast.com Phone: NOTE: Type 1 and 2 applications may be
Contact name:
Van Mesplay emai1ed to rowperllutsfj(ueard-or.eov.
Phone: (971) 801-5787 Email: Van_Mesplay@comcast.com
CONTRACTOR INFORMATION 0 Same as applicant
Name: Tennessee Cable Service CCB Number: 77450
Mailing address: 17035 SE Evergreen Hwy City/State: Vancouver, WA Zip: 98683
Phone: (503) 358-7508 Email: micki@tenncable.com/tenncs@aol.com
ENGINEER INFORMATION
Name: K&B Technical Solutions
Mailing address: PO BOX 2529 City/State: Clackamas, OR Zip: 97015
Phone: (503) 650-6041 Ext. 212 Email: Shane_Langley@kbmail.net
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 0 No Case number:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • unvwtigard-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.
rx L,., 9- as-A17
Applicant's or authorized agent's signature Print name Date
Property owner's signature (if required) Print name Date
5'1'UT 1'SI: ()NIA
Case No: f`?1,01y'(433`'1 Permit fee: Received by. , Date: "1 1
Approved by: Date: Notified by: Date:
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 S300.
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 STAFF FOR STAFF USE t,\I.\
TYPE 4: SMALL WIRELESS FACILITY TYPE 1-3:DETAILED SUBMITTAL
CHECKLIST REQUIREMENTS
Does applicant have a right-of-way license? 0 Yes 0 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 0 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:
0 Public Right-of-Way 0 Private Property Vicinity,
❑ Cover—Site, Abbreviation,Legend
If equipment is to be located on private property,describe the 0 General Notes(City,Water,Sewer,etc.)
type&use: ❑ Street(Plan,Profile)
❑ Water,Storm and Sanitary(Plan Profile)
❑ Water Qualit 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.)
❑ 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
Cl Water Provider Approval
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97221 • wwwtigard-or gov • 503-718-2421 • Page 3 of 4
Edge of Pavement
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Street&street names All existing structures
Proposed work Existing curb or edge of pavement Utility&street light poles
Existing S/\V or D/W apron Slope of property Trees
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wNwtigard-or.gov • 503-718-2421 • Page 4 of 4
Page 118 2011 Edition
Lane Closure at Intersection with Flagging Diagram 620
Diagram 620 covers work within an intersection when normal traffic control
must be interrupted. Work vehicles may or may not be in the work space.
1. During flagging, traffic signals shall be turned off. Contact the road
jurisdiction for approval and assistance (see Chapter 3).
2. For multi-lane facilities,traffic approaching the intersection shall be
reduced to a single lane on each approach. See Chapter 3 for
information on flagging through intersections.
3. There should be one flagger for each approach. One flagger may
control two adjacent approaches if sight distance, low volumes on side
roads, and flagger position allows for safe operation and clear direction
to motorists. For low traffic volume intersections (fewer than 400
entering vehicles per day), one flagger may be used.
4. 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 may be expected.
Sign Spacing and Buffer lengths(feet]
Posted Spacing Between Sire "Buffer"
Speed A B C Space
20 50
25 100 100 100 75
30 100
35 125
350 350 350
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 119
Lane Closure at Intersection with Flagging Diagram 620
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September 2016 Chapter 5
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
cannot be maintained, or when traffic cannot 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
9 P q PP 9
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
35 125
350 350 350
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 81
Shoulder Work wl Minor Road Encroachment Diaci. 300
ROAD
WORK - A ir to
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September 2016 Chapter 5
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