PFI2022-00127 DocuSign Envelope ID:6B36DA13-94A4-45AF-9888-F7C13DF6AFC5
0City of Tigard PFI#:
ENGINEERING DEPARTMENT
Public Facilities Improvement (PFI) Permit
PROJECT INFORMATION
River Terrace Town Center TYPE OF WORK
Project name: ❑ TYPE 1-Franchise Utility Work
performed byNWN,PGE, or utility
Mixed-Use Planned Dev. with
Brief description of project: agency
491 dwellings, 25,716 sf of commercial/retail space ❑ TWE 2-ROW Sidewalk/Driveway/Sewer
6 mixed-use buildings and 4 apartment buildings Work performed for the purpose of:
- Sidewalk installation or repair
- Driveway approach installation and repair
SITE INFORMATION east of SW Roy Rogers Rd & - Sanitary sewer lateral installation and
north of SW Ros h a k Rd main line tap
Location (address if available): fX TYPE 3-Full Scale Development Work
W CT M 2 S 10 6 Tax Lots 3300 & 3301 performed with land use approval which
includes any of the following:
- Subdivisions or Partitions
APPLICANT INFORMATION - Streetwidening
Name: Stanton Street Building Company, LLC • Mainline installation for sanitary sewer,
storm sewer, Tigard water, and Tigard
Mailing address: PO Box 1287 water service area
City/state: Cannon Beach, OR Zip: 97110 ❑ TYPE 4-Small Cell Technology
Phone: 503-314-0807 ❑ TYPE 5-Tigard Triangle
Email: Phone: NOTE: Type 1 and 2 applications may be
Contact name: Pam Verdadero, Sr. Vice President emailed to rowperxnitsna-,rieard-or.gov.
Phone: 503-313-7795 Email: PamV@Stanton-street.com
CONTRACTOR INFORMATION ❑ Same as applicant
Name: CCB Number:
Mailing address: City/State: Zip:
Phone: Email:
ENGINEER INFORMATION
Name: Pacific Community Design; Attention: KC Schwartzkoph, PE
Mailing address: 12564 SW Main St. City/State: Tigard, OR Zip: 97223
Phone: 503-941-9484 Email: KC[@Pacific-Community.com
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? IX Yes ❑No Case number: PDR2021-00004SUB2021-00006
Cityof Tigard - 13125 SW Hall Blvd. - Tigard,Oregon 97223 - www.tigard-or.gov - 503-718-2421 - Page 1 of 4
DocuSign Envelope ID:6B36DA13-94A4-45AF-9888-F7C13DF6AFC5
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.
Docu Signed by:
rA* VW4,lre Pam verdadero 3/22/2022
4CA6265E0FA54C7...
o6dmr-authorized agent's signature Print name Date
11r7
r. Don Roshak 3/22/2022
37E7F115749F472 .
Property owner's signature (if required) Print name Date
STAFF USE ONLY
Case No: Permit fee: Received by: Date:
Approved by: Date: Notified by:---j-Date:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 Page 2 of 4
DocuSign Envelope ID:6B36DA13-94A4-45AF-9888-F7C13DF6AFC5
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 Pen-nit Fee).
WATER LINE CONSTRUCTION FEE
Part 3: All public water system improvements engineer's estimate X 12%.
FOR STAFF USE ONLY • ' STAFF USE ONLY
TYPE 4: SMALL WIRELESS FACILITY TYPE 1-3:DETAILED SUBMITTAL
CHECKLIST REQUIREMENTS
Does applicant have a right-of-way license? ❑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 ❑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:
❑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)
❑ 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 • www.tigard-or.gov • 503-718-2421 • Page 3 of 4
DocuSign Envelope ID:6B36DA13-94A4-45AF-9888-F7C13DF6AFC5
SW
Edge of Pavement
Ditch ---4P
Streetlight I •—•—.—•—•—• —r—•—
f. i s
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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 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 • www.tigard-or.gov • 503-718-2421 • Page 4 of 4