PFI2021-00462 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT VOID
Request for Permit Action
T I G A R I) 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(i)one
REFUND OR Name:
INVOICE TO: (Business or Individual) P G E
Mailing Address: 22►3 5 ) 1 3 R
City/State/Zip: BeitvrN'-vr1I
Phone No.: S d 3 Z - ,S91102
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#: Pr 12011 - O ilfiZ
Site Address or Parcel #: y'D ski Ojvert-r bv�q .
Pe le Name: P E m 3114f l j 2- cl
Subdivision Name: Lot#:
EXPLANATION: ?Fr nab- KeviEvei T ,5 'b fnv',t-r
Signature: % Date: 1I`l /w2R_
Print Name:
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 l y 22. By TE3 Route to Records: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date \\\Z`2Z By Parcel Tag Added: Date By
I:\Building\Forms\RegPemutAcrion_120518.doc
V (_ a 1 1.I
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City of Tigard ' PFI #: 2021-00462
C ENGINEERING DEPARTMENT
TIGARD Public Facilities Improvement 1PFI) Permit
PROJECT INFORMATION
PGE Job # M3114772 TYPE OF WORK
Project name: 8 TYPE 1—Franchise Utility Work
Brief description of project: **City of Tigard Permit for Traffic peormed by NWN,PGE, or utility
agency
Control Only on SW Washington Sq Rd** Permit needed for ❑ TYPE 2—ROW Sidewalk/Driveway/Sewer
traffic control at PL 6607 across from 9640 SW Greenburg Rd 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): 9640 SW Greenburg Rd line tap
0 TYPE 3—Full Scale Development Work
Portland, OR 97223 performed with land use approval which
indudes any of the following
• Subdivisions or Partitions
APPLICANT INFORMATION • Street widening
Name: PGE [Nigel Khan] • Mainline installation for sanitary sewer,
storm sewer, Tigard water, and Tigard
Mailing address: 2213 SW 153rd Dr water service area
City/State: Beaverton/OR Zip: 97003 ❑ TYPE 4—Small Cell Technology
Phone:
503-672-5462 ❑ TYPE 5—Tigard Triangle
Email: crewcoordination-western@pgn.com Phone: NOTE: Type 1 and 2 applications may be
Contact name:
Amy Sweany emailcd to j)wpermitsailigard-or.gov.
Phone: 503-612-2935 Email: crewcoordination-western@pgn.com
CONTRACTOR INFORMATION El Same as applicant
Name: CCB Number:
Mailing address: City/State: Zip:
Phone: Email:
ENGINEER INFORMATION
Name: PGE
Mailing address: City/State: Zip:
Phone: 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? DYes ElNo Case number:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-oxgov • 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.
4,1 Nigel Khan 12/29/2021
Applicant's o authorized signature Print name Date
Property owner's signature (if required) Print name Date
STAFF USE ONLY
Case No: PFF2021-00462 Permit fee: Received by: SPV Date: 12/29/2021
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
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 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 El 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:
❑Public Right-of-Way 0 Private Property
❑ Cover—Site,Vicinity,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 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.)
O Engineer's Construction Estimate
Additional Submittals
(per land use conditions,if applicable)
❑ Traffic Report
O 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 • w wtigard-or.gov • 503-718-2421 • Page 3 of 4
9 s«- '• \- '• sI
Edge ofPavement
Ditch
Streetlight (1II - 7
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TYPE 1 AND TYPE 2:
MINIUM SKETCH REQUIREMENTS (Put N/A if nit 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 • «wwtigard-or.gov • 503-718-2421 • Page 4 of 4
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c00a, Permit needed for traffic control at PL 6607 across from
Crew Notes: Remove Existing Meter 242978901N and 1PH UG Service due to demo 9640 SW Greenburg Rd
PGE CONSTRUCTION DRAWING
Foreman: Dale:
General Foreman: Date:
(SgneluM only retOr S for SEW construction chNNea)
SOAVE/VG REVIEW I4SBU/LT BY DESIGNER:
DATE SCALE ACCOUNT AWO {1De NO
12/15/21 IM3114772
nne
Portland General Electric
ATTENTION; CALL 811 BEFORE YOU DIG ` CIRCUIT SIZE
OREGON LAW REQUIRES YOU TO FOLLOW RULES ADOPTED 11 X 17
RE THE OREGON UTILITY NOTIFICATION CENTER.
THOSE RULES ARE SET FORTS IN OAR 952-001-0010 1 /THIN\ �� LOCATION
9640 SW Greenburg Rd Portland 97223
THROUGH 951-001.0030 YOU MAY OBTAIN COPIES OF RIPPOFWAY PERMIT NOTICE: ` SCF{WfON
THE RULES BY CALLING THE OREGON UTILITY �r SAFETY "PE°'°T m°"THE Ln�'""D1�°^'IS REQUIRED
E N^WOW
mitt nestled for traffic contra at PL 8807 across from 964D SW G er R I
+� IN TLE RIPRLFWAY MAY BE PERFORMED.CHY K£APPROVED COUNLYingtOn SEipy WORK WITH
NOTIFICATION CENTER ADMINISTRATION THE032-198J) p CONRACBORS MP CONTRACTORS WNO NAVE MADE WIPER SPECIAL
Wh ngton � I OF 1
TO REQUESTLITYNUTILITY LOCATES CALL OREGON know what's below, \IRS' AGREEMENTS WTI ME WILL N ALLOWED To PAWS UNDER PC£S PERMIT.
UTILITY BUSINESS
AYSPRI PRIOR TO
BI3 AT LEAST WE CONTRACTORMUST NOTIFY iNELax JURISDICTION HOURS aeAYnrox DESIGN RV PHONE AIS0DHA S BY
IITY NOTIFICATION
CENTER,
EXCAVATION Call bMae you dig. BEFORE WORK o TO BEAN.A COW OF THE PERMIT MUST OE ON SITE, N uFs eAeMpexreR Amy Sweeny 503812-2935
PFAIPRrnx on urns 0 PORTLAND GENERAL ELECTRIC CO-ALL RIGHTS RESERVED
www.nvarion.corn
ODOT PERMIT R o o0,
oWNm: PROER/AR NUAO9. I /
PGE(Beaverton ICC) M3114772
350'+/- / /
PROTMr NOMRG ODCATON: Cm/STATE: /
9640 SW Greenhur5 Rd Tigard,OR /
143)
MAECONnNCTOR 3Oa3r /
Obi tz / /
PGE /
CONTACT NAME/NUMa9: MAN: /
350'+/- / /
PREMED BY: MOW CONTROL COPNRACTOA / /
C Borden Potelco Inc 1O//ile/1i / /
1 /
POTEL N CO IC 3N»�/a /
DEVICE SPACING: 350
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N 1 , /
TAP ER:20'
TANG ENT: 40'
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Summit Dr
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Pole 0/6607 / /
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=SW Washington Square Rd J
Hg x 7 RO'lb
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All signs and devices SHALL conform to the
MUTCIYOTTCH. /
Will adjust to fit field conditions as needed for safety.
Plan NOT toscale.