PFI2020-00269 r
City of Tigard Permit#:PFI2020-00269
p ENGINEERING I PUBLIC WORKS
Return to City of Tigard After
. Encroachment Permit Recording
PROJECT INFORMATION
Project Name: POD Storage Container
Is This Encroachment: A Furnishing? ❑ Underground System? ❑X Privately Owned Structure? ❑ Hardscape? ❑
*(See TMC 15.16 for definitions)
SITE INFORMATION (Include:Site address,proposed use of right-of-way,proposed time frame, contractor information, and
scale drawing of encroachment and its relationshp to adjoining properties):
SW Ash Avenue in Ti_ard (Street Parking Placement)
APPLICANT / PROPERTY OWNER INFORMATION I Is Applicant Same as Property Owner? ® Yes ❑ No
Applicant Name:Blossom Zelaya Property Owner Name:
Applicant Address: 12790 SW Ash Avenue Property Address:
City:Tigard State: OR Zip: 97223 City:_ State: _ Zip:
Phone:503-997-7369 Email: leizelaya@outlook.com Phone: Email:
THIS ENCROACHMENT PERMIT IS SUBJECT TO THE PROVISIONS OF Tigard Municipal Code
Chapter 15.16. I certify that the information provided in this application is true and correct to the best of my
knowledge. I have read, and I agree to be bound by Tigard Municipal Code Chapter 15.16.
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Applicant Signature: Print Name of Applicant: Blossom Zelaya
Property Owner Signature: Print Name of Property Owner:
IF INSURANCE IS REQUIRED BY CITY OF TIGARD:
Insurance Policy No. Policy Expiration Date:
Received by: Date: Permit Fee:
Reviewed by: Date: Additional Fees:
City of Tigard 13125 SW Hall Blvd. Tigard,Oregon 97223 www.tigard-or.gov 503-718-2421
TIGARD MUNICIPAL CODE 15.16
ENCROACHMENT PERMITS
Standards for Approval:
1.The proposed encroachment is 2. Furnishings must identify the name
expressly authorized by the Tigard Community and address of the owner on the exterior of the
Development Code or is otherwise in the public object,as well as an emergency contact number.
interest and consistent with the City s Public
Improvement Design Standards. 3. Furnishings must maintain a
weather proof or weather resistant quality.
2.The proposed encroachment does
not interfere with the existing or future 4. Furnishings must be designed to be
transportation system or the provision of public stable and self-supporting under a wind load of at
utilities. least 20 pounds without attachment to the
pavement or other object.
3.The proposed encroachment does
not impede vision clearance or sight distance,
pursuant to Tigard Community Development
Code Chapter 18.920 or the current AASHTO
publication, A Geometric Design of Highways
and Streets, whichever is more restrictive.
4.The proposed encroachment does
not prevent access to,cover,or block the flow of
water to or into catch basins,ditches,or swales,
and does not otherwise alter the natural drainage
patterns in a manner that adversely affects other
property.
5.The proposed encroachment
maintains minimum applicable vertical clearance
for encroachments within the right-of-way,as
provided in the Tigard Community Development
Code or Manual on Uniform Traffic Control
Devices.
6.The proposed encroachment must
meet minimum horizontal clearance from public
facilities, such as manholes and fire hydrants,as
set by the relevant service provider.
B. Standards of Approval for Furnishings:
In addition to the standards provided in Section
15.16.050.A,approval of furnishings as
encroachments must meet the following additional
standards:
1. Furnishings may not be chained,
bolted,or otherwise attached to any fixture,tree,
or item located in the right-of-way,nor attached to
the surface of any right-of-way.
City of Tigard PFI#:
p ENGINEERING DEPARTMENT
Public Facilities Improvement (PFI) Permit
PROJECT INFORMATION
TYPE OF WORK
Project name:_POD Storage Container TYPE t Franchise Utility Work
Brief description of project: _Placement of POD storage container_ performed by NWN,PGE, or utility
agency
_on SW Ash Avenue in Tigard TYPE 2 ROW Sidewalk Driveway utility
Work performed for the purpose of-
Sidewalk
£Sidewalk Curb installation or repair
Driveway approach installation and repair
SITE INFORMATION Sanitary Storm Water lateral service
Location (address if available):_SW Ash Avenue installation and mainline tap
TYPE 3 Work performed with without
land use approval which includes any of the
following:
Subdivisions and Partitions
APPLICANT INFORMATION
Water Infrastructure
Name: _Blossom Zelaya Street Widening
Sanitary o r Storm Sewer Infrastructure
Mailing address:_12790 SW Ash Avenue Apt#255
TYPE 4 Small Cell Technology
City State: Tigard Zip:_97223
TYPE 5 Tigard Triangle
Phone: 503-997-7369
Email: leizelaya outlook.com Phone: NOTE: Type 1 and 2 applications may be
emailed to rowpermits tigard-or.gov.
Contact name:_Blossom Zelaya
Phone:_503-997-7369 Email:_leizelaya outlook.com
CONTRACTOR INFORMATION X Same as applicant
Name: N A CCB Number:
Mailing address: City State: Zip:
Phone: Email:
ENGINEER INFORMATION
Name:
Mailing address: City State: Zip:
Phone: Email:
ADDITIONAL INFORMATION
Estimated value of work is required(if over 5,000): _N A (within the public right-of-way)
Is work related to a LAND USE DECISION? ❑Yes X No Case number:
City of Tigard 13125 SW Hall Blvd. Tigard,Oregon 97223 www.tigard-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
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.
f
Blossom Zelaya 7 21 2020
Applicant s or authorized agent s signature Print name Date
Property owner s signature (if required) Print name Date
•
Case No: Permit fee: Received by: Date:
Approved by: Date: Notified by: Date:
-AAM-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 Perniit Fee.See below for calculations.Minimum of 300.
NET PFI PERMIT FEE
Part 2: All non-water system improvements engineer s estimate 7 (less the initial PFI Permit Fee).
WATERLINE CONSTRUCTION FEE
Part 3: All public water system improvements engineer s estimate 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, icinity,Abbreviation,Legend
If equipment is to be located on private property,describe the ❑ General City Utility Notes Tigard Conditions of Approval
type use: ❑ Street(Plan,Profile)
❑ Water,Storm and Sanitary(Plan Profile)
❑ Water uality 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
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TYPE 1 AND TYPE 2:
MINIUM SKETCH REQUIREMENTS (Put N/A if not
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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
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! Map Created: (503)639-4171
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