PFI2022-00052 City of Tigard PFI#:
ENGINEERING DEPARTMENT
• . Public Facilities Improvement (PFI) Permit
PROJECT INFORMATION
12-3 � W Ait) � TYPE OF WORD
Project name: S ❑ TYPE 1-Franchise Utility Work
Brief description of project: performed by NWN,PCTE, or utility
agency
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I� TYPE 2-ROW Sidcavalk/Driveway/Sewer
\Work performed for the purpose of:
• Sidewalk installation or repair
• Driveway approach installation and repair
SITE INFORMATION • Sanitary sewer lateral installation and
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Location (address if available): ��– �5 !�!1 main line tap
0 TYPE 3-Full Scale Development Work
L
��� �-� `� `Z j 3 performed with land use approval which
- - includes any of the following:
• Subdivisions or Partitions
APPLICANT INFORMATION • Street widening
�Z V • Mainline installation for sanitary sewer,
Name' / storm sewer, Tigard water, and Tigard
Mailing address: I e—r C 3 water service area
City/State: _._ o`�`�d � / 0 _ Zip: 2 d A— ❑ TYPE 4-Small Cell Technology
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r^ ❑ TYPE S-Tigard Triangle
Phone: � /��Email: di I�4Ql�7(���1 �d?C l D�2�jQN R Phone: NOTE: Type 1 and 2 applications may be
f eek emailed to ro cnnits(c lt=d-or. crv.
Contact name:_��' �� 61e4-I
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Phone: ,-�J, ",>jY�? 61<{ (o Email:
CONTRACTOR INFORMATION ASameas applicant
Name: CCB Number: j f
Mailing address: Cit)r/State: Zip:
Phone: Email•
ENGINEER INFORMATION
Name:
INfailing address: City/State: Zip:_
Phone: Email:
ADDITIONAL INFORMATION
Estimated value of work is required(if over$5,000):$ y' (within the public right-of-way)
Is work related to a LAND USE DECISION? ❑Yes KNo Case number: _ ____
City of Tigard • 13125 SSG'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.
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Applicant' r 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:
City of Tigard • 13125 SVS 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 S300.
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 120/6.
FTYPE 4: SMALL NNII IRELESS FACTLIT'V TYPE I —3: DETAILED S(JB,!N,ll'1-1'AL
CHECKLIST
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 HallBlvd. Tigard,Oregon 97223 • www:tigard-or.gov • 503-715-2421 - Page 3 of 4
Edge of Pavement
- Ditch '+1'
Streetlight I —•—•—•—•----•—•--�---
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Existing House
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iI Fire Hydrant(FM)
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TYPE, I AND TYPE 2:
MINIUM SKETCH REQUIRFMENTS (put N/A if not applicable)
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North arrow T--Property lines&dimensions Existing utilities locations
(sewer,storm,water)
Street&street names All existing structures
Proposed work Existing curb or edge of pavement /Ud� Utility&street light poles
AA_Existing S/W or D/W apron Slope of property Trees
City of Tigard • 13125 SW Hall Blvd. Tigard,Oregon 97223 • www.figard-or.gov 503-718-2421 • Page 4 of 4
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