PFI2014-00083 City of Tigard
December 1, 2014
Northwest Natural
Attn: Judy Doblie
220 NW 2"'Ave.
Portland, OR 97209
Re: Permit No. PFI2014-00083
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: SEG 2020
Project Name: NW Natural
Job No.: N/A
Refund Method: ® Check#215715 in the amount of$300.00.
❑ Credit card "return" receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account"deposit" receipt in the amount of$
Comment(s): Refund 100% of permit fees as this is a duplicate of all work completed
under PFI2014-00090.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 0 www.tigard-or.gov
City of Tigard
Accela Refund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the RequertfrPermitActian form (if applicable) must
be attached to this request form. Refund requests are due to Accela System Administrator by
each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: Northwest Natural DATE: 11/20/2014
Attn: Judy Doblie
220 NW 2"`t Ave. REQUESTED BY: Dianna Howse
Portland, OR 97209 AK
TRANSACTION INFORMATION:
Receipt#: 198166 Case#: PFI2014-00083
Date: 10/27/2014 Address/Parcel: SEG 2020
Pay Method: CreditCard Project Name: NAV Natural
EXPLANATION: Permit created in error;see duplicate PFI2014-00090. Refund 100%of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
PFI Permit Fee 100-0000-43114 $300.00
TOTAL REFUND: $300.00
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff �'-t t'_ /iX2f,!j 5�
If under$12,500 Division Manager
If under$25,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONL
Case Refund Processed: Date: B:v7E _J_77—_E�E�
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
V
CItV of Tigard - COMMUNITY DEVELOPMENT DEPARTMENT ��//O I
r / W!y
Request Permit Action
13125 SW so Hall Blvd. - Tigard. Oregon 97223 • 503.718.2439 • www.tilzard-or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.dgard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor J4 City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) N W I(t Aa I ���
Z
Mailing Address: 20 v!l LN� '�+V�le.,
City/State/Zip: �br+(Ard C39-- 2-O l
Phone No.: 503. 22(o .421 X 4429
PLEASE TAKE ACTION FOR THE ITEMS) 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).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: P-02D14- g3
Site Address or Parcel#: WQ— '12W
Project Name:
Subdivision Name: Lot#:
EXPLANATION: �k �QGd' (h PiYyIX. �t/�UUIICYVi-t_ C��
F�12o l'�-c�of
Signature: Date:
Print Name: XAV I eS t4WAC 2,-
Refund
Refund Policy
1. The Director or Building Official may authorize the refund of
a) any fee which was erroneously paid or collected.
b) not more than 801'o of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80%of the land use application fee for issued permits.
d) not more than 801 o of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 801.of the building pemvt fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the on6nal Payer in the samc mohod in which p;1\-ment was received. Please allow 2-4 weeks for processing refunds.
• ' OFFICE
Rte to Sys Admin: Date 15Rte to drain: Date/5- / / B,
Refund Processed: Date/L /A/ By" I Invoice Processed: Date By
Permit Canceled: Date/Zt iV B Parcel Tag Added: Date B
Receipt# Date :Method Amount$
1:\Building\Forms\RegPemvtaction.doe Rev 05/25/2012
Agnes Kowacz
From: NWN Permits <nwnpermits@nwnatural.com>
Sent: Wednesday, November 05, 2014 10:13 AM
To: Agnes Kowacz
Subject: 14833 SW 72nd Av - WR# 3421294 - PFI2014-00090
We have permit#PF12014-00083 that is a duplicate to the above permit number. Please cancel permit#PF12014-00083
as the job was completed using the permit in the subject line. Please give us a refund for the cancelled permit. If this is
done by check, please send it attention me so I get it back to the appropriate account.
Thanks.
Judy Doblie
NW Natural
Engineering Coordinator
503-226-4211 X 4428
Fax 503-273-4822
ikd@nwnatural.com
nwnpermits@nwnatural.com
i
CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12014-00083
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 10/27/2014
Parcel: SEG2020
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: NW Natural
Project Description: Adjacent to 14833 SW 72nd Avenue. Install short side service,main on the 18'in ROW under asphalt.
One 4'x 5'asphalt cut over main for tie-in.SEG 2020.
Owner: FEES
Description Date Amount
PFI Permit Fee 10/27/2014 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
JUDITH RANDLE
220 NW 2ND AVE
PORTLAND, OR 97209
PHONE: 503-226-4211
Total $300.00
Please sign below to indicate acceptance of conditions and return a copy with the proposed work schedule along with names and contact
information of responsible parties before beginning work.
Permittee/Applicant ,,,.`� j_
Signature: f � preseI�1
Issued By: - w &pAIel:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12014-00083
Type: Condition Name: Status: Severity:
ROW 16-REPAIRS-LIKE MATERIALS REQ Continuing Notice
Property disturbed by construction activity shall be seeded with a standard grass mix; shrubs,flowers, barkdust,existing
signs, pavement markings, mailboxes,etc.,shall be reestablished, reinstalled or replaced,with like kind and material.
ROW 19-UTILITY LOCATIONAL CONFLICT Continuing Notice
Contractor must verify all existing utilities for both vertical elevation and horizontal location prior to start of work(pothole
before digging if necessary). Should conflicts arise and redesign or relocation of facilities be necessary, it shall be done at
the permit holders expense. Changes must be approved by the City in advance of work performance. Contractor shall
coordinate the work with affected utility agencies.
ROW 09-TRAF/NOISE CTRL-WORK HRS Continuing Notice
No work will be permitted during the hours of darkness, nor between 9:00 p.m.to 7:00 a.m. Monday through Friday, nor
between 9:00,p.m.to 8:00 a.m. Saturday, nor between 9:00 p.m.to 9:00 a.m. Sunday.
ROW 18-UTILITIES PRELOCATION REQ Continuing Notice
Oregon law requires following the rules adopted by the Oregon Utility Notification Center. Said rules are set forth in OAR
952-001-0010 through OAR 952-001-0080. Copies of the rules may be obtained from the Center by calling(503)232-1987.
If you have questions about the rules,contact the Center. NOTE: Damage to utilities shall be corrected at the permit holders
expense.
ROW 27-PROB SOLVING-RESPON PARTY Continuing Notice
The permit holder shall provide to the City Inspector, in writing,the names and 24-hour emergency telephone number of two
(2)persons who have authority to resolve problems,take corrective action and, in general,will be responsible in case of an
emergency.The permit holder shall notify the City Inspector, in writing, of any/all assignment changes.
ROW 06-TRAF CTRL-ADVANCE WARNING Continuing Notice
Advance warning of imminent traffic disruption shall be provided to the general motoring public by placement of an advance
notification sign at each end of the construction area 72 hours(min.)before initiation of construction work.
ROW 28-CONSTR SAFETY-RESPON PARTY Continuing Notice
The permit holder shall cause his contractor to provide to the City Inspector, in writing,the name and 24 hr emergency
telephone number of a designated"Competent Person"responsible for construction safety as per OR-OSHA, Chap.437,
Div. 3 Construction,Subdivision P-Excavations.The contractor shall notify the City Inspector of any/all assignment
changes.
ROW 05-TRAF CTRL-ROAD CLOSURE Continuing Notice
Public roadway shall not be closed to traffic, at any time,without having first obtained written approval from the City
Engineer.The permit holder is responsible for provision of timely notification of traffic flow disruptions to area wide
Emergency Services(Tigard Police Dept.,Tualatin Fire&Rescue)and to Tri-Met and Tigard School District.
ROW 02-PERMIT&PLAN REQ ON SITE Continuing Notice
A copy of the permit and all attachments, and a copy of the approved construction plan and all amendments shall be
available at the work area. All work shall conform to the permit terms,conditions and provisions and to the City approved
permit plans, and approved plan amendments and to the City's Standards and Specifications and to these General
Conditions. Changes to any of the aforesaid must be approved by the City, in advance of work performance.
ROW 03-TRAF CTRL-SPECIF(CITY) Continuing Notice
The City's standard specification for traffic control is"Manual on Uniform Traffic Control Devices for Streets and Highways",
U.S. Dept.of Transportation, F.H.A., 1988 Ed.
ROW 04-TRAF CTRL-CONTR RESPON FOR Continuing Notice
Traffic control shall be provided for by the contractor in accordance with the City's standard specification and, also, in
accordance with a City(job specific)approved traffic control plan.A copy of the approved traffic control plan shall be
available at the work area.
ROW 23-DAILY INSP REPORTS REQ Continuing Notice
The permit holders Engineer/Inspector shall submit daily inspection reports, on a weekly basis,to the City's Inspector. (see
Developer-Engineer Agreement note#5).
ROW 01-CUSTOM CONDITION Continuing Notice
Street is on 2014 no cut list. Repair 4x5'cut with attached Blanket Inlay. No traffic restrictions from 6:00 a.m. to 9:00 a.m.
and 3:30 p.m.to 6:00 p.m.
ROW 11-TRAF CTRL-CITY CAN MODIFY Continuing Notice
The City reserves the right to add to or modify traffic control requirements as may be necessary to effectively control traffic
and to assure public safety.
ROW 13-HAZARDS-CERT OF INS Continuing Notice
Maintenance of the work area and approach roads is the responsibility of the permit holder.The work area and approach
roads shall be maintained in a clean condition,free from obstructions and hazards.A copy of the permit holders Certificate
of Insurance shall be available at the work area.
ROW 10-TRAF CTRL-MIN LANE WIDTH Continuing Notice
Minimum travel lane width shall be eleven(11)feet; pedestrian travel shall also be provided for.
ROW 07-TRAF CTRL-PRIV PROP ACCESS Continuing Notice
Access to existing properties shall be maintained at all times, including normal delivery service and mail service and if not,
shall be cause for work stoppage until effective access is established.
ROW 08-TRAF CTRL-DEVICES IN PLACE Continuing Notice
Traffic control devices,flagpersons,etc., shall be in place prior to initiation of construction work and shall be effectively
maintained.
ROW 12-INSP 24 HR NOTICE REQUIRED Continuing Notice
The permit holder or his contractor shall notify the City's inspector Kenny Fisher at 503-816-6146 or email at
kenny@tigard-or.gov,twenty-four(24)hours prior to commencing work,twenty-four(24)hours prior to any staged
inspection, and after completing work covered by the permit.
ROW 14-DEBRIS-MATERIALS Continuing Notice
The spreading of mud or debris or storage of materials or equipment of any kind upon any public roadway is strictly
prohibited and violation shall be cause for immediate cancellation of the permit.The City may at any time order immediate
cleanup and stoppage of work to accomplish cleanup.
ROW 15-EROSION CTRL REQ Continuing Notice
Effective erosion control is required. Erosion control devices must be installed and maintained meeting D.E.Q.
requirements.The City may at any time order corrective action and stoppage of work to accomplish effective erosion
control.
ROW 20-TRENCH-PATCH/SAFETY/LBILITY Continuing Notice
A temporary hard-surface patch(Cold mix A.C.or Hot mix A.C. base paving) shall be placed on trenches within roadways
at the end of each day's work. No trench,on site or off site,shall be left at any time in an unsafe condition.The permit
holder is responsible for and is liable for hazards or damage resulting from the work.
ROW 17-DRAINAGE CONTROL REQ Continuing Notice
Effective drainage control is required. Drainage shall be controlled within the work site and shall be so routed that adjacent
private property, public property and the receiving system is not adversely impacted.The City may, at any time, order
corrective action and stoppage of work to accomplish effective drainage control.
ROW 24-TESTS/REPTS TO VALIDT CLMS Continuing Notice
The City's Inspector may, at their discretion, require provision of tests and or reports from the permit holder, permit holder's
engineer or contractor to validate claims of material or construction adequacy/compliance. Such tests/reports shall be
provided at the permit holder's expense.
ROW 26-MONUMENT PROTECTION REQ Continuing Notice
Existing monuments, property corners,and survey markers shall be protected. Replacement shall be at the permit holders
expense.
ROW 21-REPAIRS REQ-INSPTR OPINION Continuing Notice
Work provided for under the permit shall include repair of existing facilities(roads,ditches,etc.)as may be necessary, in the
City Inspectors opinion,to overcome deterioration or damage which occurred in conjunction with the work authorized by the
permit. Corrective work shall be done at the permit holders expense.
ROW 22-AS-BUILT/ENGR CERTIF REQ Continuing Notice
At the end of each year, or an a mutually agreeable yearly date, any entity making changes to its facilities in the public
right-of-way shall submit complete"as-built"drawings showing all new public improvements, including any revision made to
the previously approved construction plans and, also,any improvement which may impact an existing public system or
facility, shall be provided to the City by a registered civil engineer along with an engineers certification of installation
compliance(form attached).
ROW 25-RELEASE-WAIVER REQ Continuing Notice
The permit holder shall provide a copy of a properly executed Release&Waiver document to the City for each ownership
disturbed by construction activity, as evidence of disturbance resolution and owner satisfaction.
ROW 29-ESMT/RT OF ENTRY-RESPON Continuing Notice
It is the sole responsibility of the permit holder to provide for proper right-of-entry and/or easements prior to starting work.
Proof of right-of-entry,or properly executed easements,shall be provided to the City.The City shall in no way be construed
to be liable for the permit holder's failure to obtain or provide for proof of right-of-entry or easements.
REG ,. "D
City of Tigard OCT 0 1 2014
U Public Facility Improvement CITy
PlANNaNi" s :`ar t_: ai4�G
(PFI) Permit , ,G�S
General Information: FOR STAFF USE ONLY
Property Address/Location(s): 14833 SW 72nd Ave EngineeringPEI
�,�
Case No.: T t 12014-CM-93
SGLaI ��/ Feer 3610 1�t'
Receipt No.:
*Applicant's Name:NW Natural Date:
220 NW 2nd Av Application Accepted: 10 t B
Address: PP � P By:
City/State:Portland OR Zip:97209 105
u
Primary Contact: Judith Randle REQUIRED SUBMITTAL
Phone:503-226-4211 X 4334 Fax:503-273-4822 INFORMATION
E-Mail: nwnpermits@nwnatural.com Professional Engineered Plans are required
for:
Same • Street Widening
Contractor's Name: . Subdivision Infrastructure
CCB# Expiration: • Main utility line extension:
0 Storm Drain,Sanitary—Tigard
Address: 0 Water—Tigard Water Service Area
City/State: Zip: (includes Durham,King City and a
portion of unincorporated Washington
Phone: Fax: County)
"Note:See Engineered Plan
Plans By: Submittal Checklist attached.
Address: For all other work Submit scaled sketch of the
City/State: Zip: work to be done. (see attached minimum sketch
Phone: Fax: requirements and provided sketch area).
Updated:6/24/2013
I:\CURPLN\Masters\land Use Applications\Public Facility
Description of work:
Install short side service, main on the 18' in Improwment.docx
ROW under asphalt. One 4'x5'asphalt cut over main for tie-in.
'z—_ R aja.errial,
Estimated value of work(within the public right-of-way): $
Is work related to a LAND-USE DECISION? YES [—] NO ❑
If so,please specify(MLP,SDR,SUB,etc.) case#:
Is the work related to a BUILDING PERMIT? YES❑ NO ❑
If so,please specify (BUILDING PERMIT) case #:
City of Tigard 13125 SW Hall BBlvd.,,�Tigard,OR 97223 503-718-2464 www•.tigard-or.gov Page I of S
ho 6.I, '„ - 1=vv,�... . a-,.� 3: 3 0lo fie` 6� coo
APPLICANTS:
To consider an application complete,you will need to submit ALL of the REQUIRED SUBMITTAL ELEMENTS as described on
the front of this application in the"Required Submittal Elements"box.
NOTE: Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for work.
*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(s)must sign this application in the space provided on the
back of this form or submit a written authorization with this application
(Detailed Submittal Requirement Information sheets can be obtained,upon request,for all types of Land Use Applications.)
BY SIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT:
♦ The above request does not violate any deed restrictions that may be attached to or imposed upon the subject property.
♦ If the application is granted,the applicant will exercise the rights granted in accordance with the terms and subject to all the conditions
and limitations of the approval.
♦ All of the above statements and the statements in the plot plan, attachments, and exhibits transmitted herewith, are true; and the
applicants so acknowledge that any permit issued,based on this application,may be revoked if it is found that any such statements are
false.
♦ The applicant has read the entire contents of the application,including the policies and criteria,and understands the requirements for
approving or denying the application.
SIGNATURES of gam}owner of the subject property.
DATED this 30th day of September 2014
Digitally
signedj2rn ralom
ON:cn=j2@wa[ural.a
Data:2014.09.30 1225:30-0-rW
Applicant/Authorized Agenes Signature Owner's Signature
Owner's Signature Owner's Signature
City of Tigard 1 13125 SW Hall Bbd.,Tigard,OR 97223 1 503-718-2464 1 www.dgard-or.gov I Page 2 of 5
Machine Mill The Sond And Seal
Exstin
12Area For A 1-1/2" Paving Joints With
hal
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Asphaltic •
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1
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'T' Patch, 6' Thick Or Match •. j. _ I } I: Ground
Existing Pavement (whichever is
Greater) Up To The Level O/
Original Pavement.
(�._�i � • ;.• •� •. 't � - III_
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Material -
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Trench Width
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*Notes: As Specified
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8° " Blanket Patches To Be Constructed With Level 2, 1/2 Inch, Dense, Pg-64-22
i Hmoc In Dry Pavement Conditions, Where Existing Pavement Is At Least 60' F
And Rising.
>Z • Tock All Pavement To Be Inlaid With Emulsified Asphalt.
m • The City Engineer Shall Determine the Final Width and Length of the Inlay Patch
y�
to Best Fit Travel Patterns.
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CAPITAL CONSTRUCTION AND
4 TRANSPORTATION DIVISION City of Tigard FIGURE
a�9 13115 sw �„` HLYD. Utility Trench - Blanket Inlay UT-BI
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NW N5tural PLAT: 1-045-022 COUNTY: WASHINGTON 09118/14 10:14
(503)226-4211 TOWNSHIP: T02S RANGE: R01W SECTION: 12NE SCALE: 1 IN=196 FT USER ID:rtp
Page 106 2011 Edition
Diversion into a Continuous Left Turn Lane Diagram 430
Diagram 430 shows work in the travel lane(s) next to a continuous two-way
left turn lane with one direction of traffic diverted into the continuous two-way
left turn lane.
1. Use truck-mounted flashing warning lights on work and protection
vehicles. See Section 4.3—Lights and Lighted Signs for exceptions.
2. For added visibility, a truck-mounted arrow board or PCMS in caution
mode may be used.
3. When two or more travel lanes are reduced to a single lane before the
diversion, each lane shall be closed separately. Layout traffic control
according to ODOT Standard Drawing TM 852 for 5-lane sections.
4. A shifting taper(U2) may be added in the diverted traffic direction
across the continuous two-way left turn lane(as shown). This option is
recommended when the speed is 45 mph or greater.
Sign Spacing and Buffer Lengths(feet)
Posted Spacin Between Signs Buffer
Speed A B C Space
20 50
25 100 100 100 75
30 100
35 40 350 350 350 125
150
45 180
50 500 500 500 210
55 250
Chapter 5 December 2011