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PFI2015-00090 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT RECEIVED ■ Request for Permit Action JUN 2 9 2015 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • I `TIGARD NG DIVISION TO: CITY OF TIGARD V ® ,, Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 y Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPerrnits@tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) (�a 0( em Mailing Address: UrTStC City/State/Zip: � Qrj` lX C)2 17 ,Vyo Phone No.: 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). ❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit #: Site Address or Parcel#: �SC� �� 1�� f LOA. d� Project Name: GX L'jt,�i/ r ] T Subdivision Name: Lot#: EXPLANATIO : .1- Fr Signature: , Date: 029 S' 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 By Route to Records: Date 9 / B Refund Processed: Date By Invoice Processed: Date B Permit Canceled: Date / BYA Parcel Tag Added: Date B I:\Building\Forms\RegPermitAction_09 1 .doc City of Tigard RECEIVE® ■ PUBLIC WORKS—ENGINEERING JUN 2 4 2015 Public Facility Improvement (R1V&TNT1kftNG DESCRIPTION OF�K(in the right-of-way) REQUIRED SUBMITTAL E]Check one: Utilities idewalk/driveway approach ❑ Street improveme is ELEMENTS Detailed description: ❑ Minor work in right-of-way (sidewalk repair,curb cut,street ( � opening,etc.)requires: •Application form,completed and signed �p •Submit one(1)copy of scaled sketch Property address location(s): ��S V � (1/� of the proposed work to be done }� •Submit one(1)copy of traffic control plan –OR– A Applicant's name: (' ❑ Substantial project work requires pP above items and professional Address: t engineered plans for: � •Street widening City/state: Zip: •Subdivision infrastructure Phone: •Main utility line extension: Storm Drain,Sanitary–Tigard Water–Tigard Water Service Contractors name: SO Area(includes Durham,ting City CCB#: ( I Expiration: 4,7 and a portion of unincorporated Address: h QWashington County) s�� DELIVER APPLICATION TO: City/state: f`coa Zip: 7 `7 i City of Tigard Phone,, `3 dEmail: Planning/Engineering 13125 SW Hall Blvd. Engineer's name: Tigard,OR 97223 Applications for"minor work in right-of-way" Address: only may be emailed to: City/state: Zip: .tigard-oror.gov Phone: Email: FOR STAFF USE ONLY OiEstimated value of work(within the public right-of--way): $ Case No.: 2–015—0 D Application submittal fee: Is work related to a LAND-USE DECISION? ❑ Yes ❑ No Application accepted: If so,please specify (MLP, SDR,SUB, etc.) case #: By: NZ . Date: Ap c revt d: Is work related to a BUILDING PERMIT? ❑ Nes ❑ No If so,please specify(BUILDING PERMIT)case#: B App'Gant a'h /N f By: Date: I:\CURPLN\Masters\Land Use Applications Rev.07/16/2014 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. *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 or submit a written authorization with this application. 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 properl;. • 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 each owner of the subject property required. Applicant/Au orized Agent's signature Print name Da Owner's sign re Print name Dat, Owner's signature Print name Date Owner's signature Print name Date PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2421 • Page 2 of 4 DEVELOPMENT ENGINEERING FEES 1. Public Facility Improvement(PFI) Permit: Part 1: Required submittal fee$300.00 Part 2: All non-water system improvements Engineer's estimate X 5%(less$300.00 submittal fee) Engineer's estimate X 2%Plan Review Part 3: All public water system improvements Engineer's estimate X 12% Total Permit Fee = Part 2 + Part 3 PFI Permit Fee Exemptions: There will be no permit fee charged,or assurance required for the following types of work: • Sidewalk or driveway repair(less than 20 lineal feet) • Relocate or replace mailbox • Ditch cleaning that does not involve regrading. • Weephole repair • Curb repair or replacement(less than 20 lineal feet) • Lawn sprinkler system installation or repair • Street tree pruning or planting • Planter strip landscape maintenance • Test wells PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 www.tigard-or.gov 503-718-2421 Page 3 of 4 SAMPLE SKETCH: Edge of Pavement Ditch V Streetlight •I ------------- —r--- • a Rain,Dns, 1 I I , ' T–fir o'p os cf'Selw'e i'Ti'n e" � Existing House Existing F, I :1 1 Driveway 0I I �! 1 0 o� o� s' Existing Shop C) Powerpole I I ��. . - I� 9S' I ------- ---------- I �property Line- ' I ia I Fire Hydrant(FH) � � I Scale: 'I"=30' � I I I I I I � I MINIMUM SKETCH REQUIREMENTS (Put"N/A" if Not Applicable): North arrow Property lines &dimension Slope of property Street&street name(s) Existing building, structures Utility&street light poles Proposed work Existing curb or edge Trees Existing S/W or of pavement Existing utility locations D/W apron (sewer,water, storm) PUBLIC FACILITY IMPROVEMENT PERMIT Cite of Tigard - 13125 SW Hall Blvd. - Tigard,Oregon 97223 - www.tigard-or.gov - 503-718-2421 - Page 4 of 4 1 hill A y- 4 S2 V/1 r , o o v r 0 a � N @ 6 N C Kenny Fisher From: Tim Lehrbach Sent: Thursday, June 11, 2015 4:31 PM To: Greg Berry, Karleen Aichele; Kenny Fisher Subject: FW: City of Tigard Public Facilities Improvement Permit Attachments: ASBUILT_Womens Health 7650 SW Beveland St_Design Packet-01222015.pdf FYI From: Jeff Mettert [mailto:Jeff Mettert(a)kbmail.net] Sent: Thursday, June 11, 2015 4:29 PM To: Tim Lehrbach Cc: Todd Hurd <todd.hurdCablevel3.com>; Justen Phillips Subject: RE: City of Tigard Public Facilities Improvement Permit Tim, This project has been completed and the as-builts are attached. Please call or email me with any questions or concerns. Thank you, Jeff Mettert K&B Technical Solutions 6566 SE Lake Rd Suite F Milwaukie, OR 97222 Office—(503) 650-6041 Fax—(503) 650-7390 Jeff—Mettert@kbmail.net From: Tim Lehrbach [mailto:TimL(a>tigard-or.gov] Sent: Monday, February 09, 2015 10:27 AM To: Jeff Mettert; david.miner-Olevel3.com; awpalmer(a)northskycomm.com Subject: City of Tigard Public Facilities Improvement Permit Good morning, Your application for work in the SW Beveland St. right-of-way is approved. Please find your permit and receipt attached. Thanks, Tim Tim Lehrbach City of Tigard I Community Development 13125 SW Hall Blvd. Tigard, OR 97223 1