PFI2021-00453 City of Tigard • COMMUNITY DEVELOPMENT DEPARTM 0 1 7 a
Request for Permit Action FF��
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: 503-598-196(1 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant (J Contractor 2/City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
Er' 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#: PFL 2oZ ! - 00453
Site Address or Parcel#: %90 Sit) 6reto bvi—q ie-d
Project Name: al02 8-/b'f
Subdivision Name: " Lot#:
EXPLANATION: (,f/ar,� ,t 5 .%-, ei JII/%i yrd h 6vn / J4i h i fl4(
rd-1 nok L;�y Of Tigavr,/ /e//�
Signature: T r rfi a'2s.•0.7 Date: 12 2.7/2U4
Print Name: Tre n I- tiv«/
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 Admin: Date 12 Z 1 21 By 1 Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date '\12,22 By c1 Parcel Tag Added: Date By
I:\Budding\Forms\RegPermi tAction_120518.doc
City of Tigard PFI#: ?A2l — O( 53
71 • ENGINEERING DEPARTMENT
T I G A R D Public Facilities Improvement (PFI) Permit
PROJECT INFORMATION
TYPE OF WORK
Project name: 00028164
r TYPE 1—Franchise Utility Work
Brief description of project: Cutting gas services to both locations below. permed by NWN,PGE, or utility
agency
Gas main is 16'west of center line. Two 4'X 5'hard surface cuts. I— TYPE 2—ROW Sidewalk/Driveway/Sewer
Work performed for the purpose of
We hope to complete work ASAP. • Sidewalk installation or repair
• Driveway approach installation and repair
SITE INFORMATION • Sanitary sewer lateral installation and
9640 SW Greenburg#Hse&#Church, Tigard
main line tap
Location (address if available): 9
I— TYPE 3—Full Scale Development Work
performed with land use approval which
includes any of the following:
• Subdivisions or Partitions
APPLICANT INFORMATION • Street widening
Name: NW Natural • Mainline installation for sanitary sewer,
storm sewer, Tigard water, and Tigard
Mailing address: 250 SW Taylor St water service area
Portland, OR 97204 E TYPE 4—Small Cell Technology
City/State: Zip:
Phone:
971 979 9615 I— TYPE 5—Tigard Triangle
Email: Jaw@nwnatural.com Phone: 971-979-6047 NOTE: Type ] and 2 applications may be
Contact name: Jennifer Wood "nailed to rowpermits dlti6'ard-or.gov.
Phone: Email:
CONTRACTOR INFORMATION E Same as applicant
Name: CCB Number:
Mailing address: City/State: Zip:
Phone: Email:
ENGINEER INFORMATION
Name: Richard Girard
Mailing address: Same City/State: Zip:
Phone: 360-921-0314 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? C Yes -No Case number:
City of Tigard • 13125 SW Hall Blvd. • 'Tigard,Oregon 97223 • wwwtigard-orgov • 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.
.t i-v.4.4.t,Ora Jennifer Wood 12/17/21
Applicant's or authorized agent's signature Print name Date
Property owner's signature (if required) Print name Date
STAFF USE ONLY
Case No: PF12021-flf)453 Permit fcc: Received by: SPV Date: 12/21/2021
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 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 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 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 [ Dimensions
considered?(check all that apply): Small Cell I Macro T Street Name
How many install sites are proposed as part of this permit • Site ddress
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 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.)
L Details
C Traffic Sight Distance
L Signing and Striping
E Street Light Plan and Photometric
L Engineers seal/signature
7 Sheet label(project land use name,revision and plan
log block,dates and sheet numbers.)
C Engineer's Construction Estimate
Additional Submittals
(per land use conditions,if applicable)
C Traffic Report
C Storm water Drainage Calculations
C Geotechnical Report
L. Preliminary Access Report(Sight Distance)
[ Proposed Plat
C Pathway Design
C Water Provider Approval
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 3 of 4
9 sw "Y" " I
Edge of Pavement
— Ditch
Streetlight
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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 ex' Ling 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
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