PFI2021-00300 •
VOID
City of Tigard • cOMMUNrrY DEVELOPMENT NT DEPARTMENT
•
■ Request for Permit Action
ti I1 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 • www.iigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 't'igardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ® Applicant ❑ Contractor ❑ City Staff
(:heck(V)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Willamette Water Supply Program
Mailing Address: 1850 SW 170th Ave.
City/State/Zip: Beaverton, OR 97003
Phone No.: (503)941-4573
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 FZ ZD 2(-CU 3d U
Site Address or Parcel#: Local roads off SW Scholls Ferry Road
Project Name: Willamette Water Supply Program-Metzger Pipeline East 1.3
Subdivision Name: loot #:
EXPLANATION: The WWSP is withdrawing its permit application and will re-submit at a later date
when design is complete and all project elements can be included.
Signature: �._�� Date: l//.31z
Print Name: ? i-i 215 ti rU A- (Ai R L T71(
Jtrftntd Policy
1. The do's Community Devektpment Director,Building Official or(:il) l nginecr mar 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 fcc for issued penults prior to any inspection requests.
2. :\ll 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.
POR OFFICE USE ONLY
Route to Sys Admin: Date\\\3") 2\ BY Route to Records: Date By
Refund Processed: Date Be Invoice Processed: Date By
Permit Canceled: Date lk\2\22 Bc41Nl Parcel Tag Added: Date By
I:\Building\I v prim\l(eyPcrmit.\n it m_13151 N.Juc
- City of Tigard pH#: PFI2021-00300
_ VO I D
a ENGINEERING DEPARTMENT
TIGARD Public Facilities Improvement (PFI) Permit
o
PROJECT INFORMATION
TYPE OF WORK
Project name: Metzer Pipeline East 1.3 DK TYPE 1—Franchise Utility Work
Brief description of project: Water supply pipeline performed by NWN,PGE, or utility
agency
❑ 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
main line tap
Location (address if available):
❑ TYPE 3—Full Scale Development Work
Local roads off of SW Scholls Ferry Road performed with land use approval which
includes any of the following:
• Subdivisions or Partitions
APPLICANT INFORMATION • Street widening
Name: Willamette Water Supply Program • Mainline installation for sanitary sewer,
storm sewer, Tigard water, and Tigard
Mailing address:1850 SW 170th Avenue water service area
City/State: Beaverton/Oregon Zip: 97003 ❑ TYPE a—Small Cell Technology
❑ TYPE 5—Tigard Triangle
Phone:
Email: nolteanbrwncald.com Phone: NOTE: Type 1 and 2 applications may be
emailed to rowpermitsatigard-or.gov.
Contact name:Nicolae Oltean on behalf of Brendan Robless
Phone: 719-930-7605 Email: brendan.robless@tvwd.org
CONTRACTOR INFORMATION ❑ Same as applicant
Name: TBD CCB Number:
Mailing address: City/State: Zip:
Phone: Email:
ENGINEER INFORMATION
Name: Brown and Caldwell. Nicolae Oltean
Mailing address:6500 S Macadam Ave., Suite 200 City/State: Portland/Oregon Zip:97239
Phone: 503-244-7005 Email: noltean(@,brwncald.com
ADDITIONAL INFORMATION
Estimated value of work is required(if over$5,000):$NA,work within WaCo ROW (within the public right-of-way)
Is work related to a LAND USE DECISION? 0 Yes ®No Case number.
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-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 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.
Nicolae Oltean 8/16/2.4
Applicant's or authorize agent's signature Print name Date
NA
Property owner's signature (if required) Print name Date
STAFF USE ONLY
Case No: PF12021-00300 Permit fee: Received by:NTuason Date: 8/10/2021
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
a
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 PFI 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 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 ❑ 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 ❑Private Property
❑ Cover—Site,Vicinity,Abbreviation,Legend
If equipment is to be located on private property,describe the ❑ General Notes(City,Water,Sewer,etc.)
type&use: ❑ Street(Plan,Profile)
❑ Water,Storm and Sanitary(Plan Profile)
❑ Water Quality 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)
O Traffic Report
O Storm water Drainage Calculations
❑ Geotechnical Report
❑ Preliminary Access Report(Sight Distance)
❑ Proposed Plat
❑ Pathway Design
D Water Provider Approval
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigardor.gov • 503-718-2421 • Page 3 of 4
9 s I .. Y •• S I
Edge of Pavement
Ditch
Streetlight -• •�•�•�•�•�r�•�
f- Rah.Drain •4.:i
® t ; / D
.o-1
1 1 •
I T--PraraffirgA rnsl:-- i
r
I ni I
›• Existing House •
of 1 Existing 1
Q • Driveway
''
�I 31 I 1
al • I Sr vi
'
iI rl
• I.
.
•
al I 1
0 1 Existing Shop 1
Powerpole I rA I I
Ic" 95'
^ IN
I 1 I Fire Hydrant(FH)
I I
II Scale: 1"=30'
I I
I
I I
I• I
TYPE I 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