PFI2022-00107 V 0
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT x
= Request for Permit Action
13125 SW Hall Blvd. • Tigard,Oregon 97223 • 503-718-2439 • u-vv.rigard-or.goN
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@dgard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor 1� 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.
❑ 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 #: ?R )JZZ- a)61 II
Site Address or Parcel#: 1 E)5go s �[/M►rilil��,�le� L�?h Z
Project Name: .S%det�� 1k
Subdivision Name: Lot #:
EXPLANATION: DqQ L& 4 PF L
Signature: , Date: 311-$1Zv?2-
Print Name: 7—re-,,j f- &-icI<
Refund Pohcv
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 $ 2 TZ B• Route to Records: I Date B
Refund Processed: Date By Invoice Processed: Date B
Permit Canceled: Date By VQ I Parcel Ta Added: Date B
I:\Building\Forms\RegPemtiLAc ion_12051 S.doc
City of Tigard PFI#: 2022-00107
ENGINEERING DEPARTMENT
Public Facilities Improvement (PFI) Permit
PROJECT INFO'R/Mfs #4iTYPE OF WORK
Project name: _ _64-f Ci/� ( �• V Q� ❑ TYPE t-Franchise Udtiey WDdc
Cj�DIiGI [� R�i VCG,11 p�otwedbyNWN,PGE, orunlry
Brief descriprion of project: -- agency
TYPE 2-ROW Sidewalk/Driveway/Sewer
Work performed for the purpose of
^ Sidewaik iagbliation Of repair
.. _. o Driveway approach insrsUarion and repair
SITE INFORMATION ^ Sa itary sewer lateral installation and
main line tap
Location (address if available): _ ❑ TYPE 3-Ful!Scale Development Wolk
6 L✓ �A/y '•� performeduse
with land approval which_ includes any of the following:
- Subdivisions or partitions
APPLICANT INFORMATION
r / l I - Street widening
�GG'V [L� Z`i(e•� a Maidm Tiga
inc installation for sanitary scwu,
Name; IV stor ,sewer, rd warcr, and Tgard
156-Yo � SuMnnG—Ki—r�L� L-411 wa�ase=<iaara
Mailing address, �p�-� ��j
City/stater r�97/�P-D V 9 ;L I- ❑ 7 YPE 4-Small Cell Tachoology l
❑ TYPE 5-Trqud Tnangle
Phone: y �� ��to --_
Email:i (� en>✓ [/ t �4 L' � � I ` r ,a 31 i� NaIT m
Type 1 and 2 applications ay be
Contact name: 5
Phone: Entail: .._ - -
CONT�R++A'�CTOR INFORM�A,TIION'1`AS2me as applicant q
CCB Number.
Mailing addre� J N5 �R City/State�
l��r V!LLFi Zip: 0 D
_: —
Phone:�J1 yaT/` — Email: - ..-Z —._
ENGINEER INFORMATION
Name: _.._._ — ---- ----- -
Mailing addtess: _ City/State: zip:— -
Phone:
ADDITIONAL INFORMATION �J
Estimated value of work is required(if over 125,000):5 L6 Q�� _ (wig the public right-of-way)
Is Work related to a LAND USE DECISION? O Yes ONo Case number __-.. -- --
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwd9atd-0zgov • 5W718-2421 • Page 1 of 4
APPLICANTS
NOTE: Person spedfied as"Applicant"shall be designated"Permittee"and shall provide financial assurance lot
work,if required by the city pursuant to TMC 15.04.140.
-nth the eaeeption of a uoliry operating pt¢suant to a valid f6nrM m license with the City of Tigard,when the owner and the applicant
ace different people,the applicant must be the purchaser of record of a lessee in possession with written authorizaritm from the owns[
of an agent of the owner. 'Me owner must sign this application in the space pmvided or submit a written authorization with this
appliation. Franchised or Licensed Utilities ate trot required to obtain the owner's sigaaaue on the application.
l the applicant,certify that:
a 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.
Applicant's or authorized agent's signature Print name
Property owners signature (if required) Print name
r 1�3Sftu�lflr�'�Co�n6'-S�
Case h : PF12022-00107 Permit fee: Received h . SPV Date:_3/22/2022
Approved by: _ Date: Notified by:_ Date:
City of Tigard 13125 SW Halt Blvd. • Tigatd,Oregon 97223 www.dgard-or gov • 503-718-2421 • Page 2 of 4
t
DEVELOPMENT ENGINEERING FEES
Public Facility Improvement(PFI)Permir.
INITIAL.PFI PERMIT FEE
Part 1: Required submittal fee is 90°/a of the Net PFI Permit Fec.See below for calculations.Minimum of$300.
NET PFI PERMIT FEE
Part 2: All non-water system improvements engineer's estimate X 70/6(less the initial PFI Permit Fel:).
WATER LINE CONSTRUCTION FEE
Part 3: All public water system improvements engincen'ls estimate X 121/6.
RU k�wmrmp 1 ON44 ST 632rd±1R$WA(014L,SY
7S�ll��i�'�4��L��I �,f�S��f �iflltjh�ti fl��I�JIFSii�5^iJ�'.�i5F1��1I.
=0 TWO I a,7[
Does applicant haw a right-of-way license? D Ycs []No TYPE 1 AND TYPE 2-Must include a sketch
showing:
Under the witetess facilities standards,is the proposal ❑ Ditnensions
considered?(check a that apply): ❑Smal]Cell ❑Macto ❑ StmtName
❑ Site Address
How many instar sites are proposed as part of this permit
application?
TYPE 3-Must provide 4 sets of plane(sized 24x36
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 ❑Private Property
❑ Cover—Site,Vicinity,Abbreviation,Legend
1f equipment is to be ktcsted on private property,descnbe the ❑ General Notes(Cit),Water,Sewer,cr-)
type&use: ❑ Street(Plan,Profile)
❑ Water,Storm and Sanitary(Plan Profile)
❑ Water Quality Fadlitum
❑ Grading
❑ Landsaying/TreePlan
❑ Composite Utility Plan PectricaL Phone,Gas,Storm,
Sanitary,Water,Signage,Street lights,etc.)
❑ Details
❑ Traffic Sight Distance
❑ Signing and Striping
❑ Stmt Light Plan sad Photometric
❑ F.ng}n«cs seal/signature
❑ Sheet label(project land use name,revision and plan
log block,dates and sheet numbers.)
[J Engineers Construction Fsdmam
Additiona]Submarals
(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 • wwwtigatd-orgov 503-718-2421 Page 3 of 4
SW St
t Edge ofPavenvad
1 s� — Duch
Streetlight I
{` ' Ran am
� I G
g Q 1 i �ay u
LO
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fl �
71Powl - j erpole ! � A@ 5
95' D
lrropi fi yline
1 1
Fin Hydra MffM
scale! t'=so'
1 1 ,
y
_North arrow Property lines&dimensions N 1 n Existing utilities locations
----- t (sewer,storm,water)
Stmtt&street names All existing st wtures
Proposed work Existing curb or edge of pavementutility&street light poles
-Existing S/W or D/W apron Slope of property Trees
City of Tigard • 13125 SW Hall Blvd. Tigard,Oregon 97213 wwtatignrd-or gov 503-718-2421 • Page 4 of 4