PFI2016-00034 n
CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12016-00034
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 03/01/2016
Parcel: SEG585
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: PGE
Project Description: Adjacent to SW North Dakota St.&SW Greenburg Rd. For sidewalk infill Tigard project. Relocate
anchor&down guy. Raising a vault lit to match future grade.
Owner: FEES
Description Date Amount
PFI Permit Fee 03/01/2016 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
TSAHAI ANDERSON
10800 SW AVERY ST
TUALATIN, OR 97062
PHONE: 503-672-5466
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 NOT PRESENT
Signature:
Digitally s,gne,J by kremy Wnson
c DN:cnskremy Hansen,wpuN,c Works Department,-u ,ty0
Pgard,email-*myh@tigard ago .US
Issued By: L Date 1016030116.-M-OBW
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12016-00034
Type: Condition Name: Status: Severity:
PFI_Utilities 02-WORK SITE AREA Not Met Notice
The work area and approach roads shall be maintained in a clean condition, free from obstructions and hazards. 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 clean-up
and suspension of work to accomplish clean-up.
PFI_Utilities 03-WORK SITE EROSION CONTROL Not Met Notice
Prior to starting work, effective and approved erosion control devices must be installed and maintained meeting the Clean
Water Services and DEQ requirements. The City may at any time order corrective action and suspension of work to
accomplish effective erosion control.
PFI_Utilities 04-WORK SITE REPAIRS Not Met Notice
Disturbed landscaped areas shall be restored or replaced. Existing signs, pavement markings, mailboxes,etc. shall be
reinstalled or replaced,with like kind of material. Obtain City approval of restoration work.
PFI_Utilities 05-TRAFFIC CONTROL SPECIFICATIONS Not Met Notice
Applicant shall provide traffic control according to the current edition of the"Manual on Uniform Traffic Control Devices
[MUTCD]for Streets and Highways", U.S. Dept. of Transportation, FHWA, current edition,American Traffic Safety Services
Association[ATSSA], and Oregon Temporary Traffic Control Handbook[OTTCH].
PFI_Utilities 06-TRAFFIC CONTROL PLAN Not Met Notice
Submit a job specific traffic control plan. A copy of the approved traffic control plan shall be readily available at the work
area.Traffic control devices, flag persons,etc., shall be in place prior to initiation of construction work and shall be
effectively maintained.
PFI_Utilities 07-TRAFFIC CONTROL ROAD CLOSURE Not Met Notice
Public roadway shall not be closed to traffic, at any time,without obtaining written approval from the City Engineer. The
applicant is responsible to provide 48 hour advance notice of traffic flow disruptions to affected businesses, residents and
area wide Emergency Services: 503-629-0111 (Tigard Police Dept.,Tualatin Fire&Rescue)and to 503-962-8140(Tri-Met)
and 503-431-2345(Tigard School District)and other service providers impacted by such closure.
PFI_Utilities 08-TRAFFIC CONTROL PROPERTY ACCESS Not Met Notice
Access to existing properties shall be maintained at all times, including normal delivery service and mail service. Obtain City
approval of any access closures.
PFI_Utilities 09-TRAFFIC CONTROL WORK HOURS Not Met Notice
Work is permitted in daylight between the hours of 7:00 a.m.to 7:00 p.m. Mon-Fri unless otherwise authorized by the City.
PFI_Utilities 10-TRAFFIC CONTROL LIMITED WORK HOURS Not Met Notice
Hours of construction work on collector and arterial roads will be limited to 9:00 a.m.to 3:00 p.m. unless authorized by the
City Engineer. Work will not be permitted on collector and arterial roads between 3:00 p.m. to 9:00 a.m. unless authorized
by the City Engineer.
PFI_Utilities 01 -WORK SITE REQUIREMENTS Not Met Notice
Applicant must comply with all applicable provisions of federal and state law,the Tigard Municipal Code, and the terms of
any agreement with the City of Tigard regarding work to be done pursuant to this permit.
PFI_Utilities 11 -TRAFFIC CONTROL MODIFICATION Not Met Notice
The City reserves the right to add to or modify traffic control requirements as necessary to effectively control traffic and to
assure public safety.
PFI_Utilities 12-UTILITY NOTIFICATION Not Met Notice
Oregon law requires following the rules adopted by the Oregon Utility Notification Center. Said rules are set forth in OAR
952-001-0100 through OAR 952-001-0080. Copies of said rules may be obtained from the Center by calling 503-246-1987.
If you have any question about the rules, contact the Center. NOTE: Damage to utilities shall be corrected at the permit
holder's expense.
PFI_Utilities 13-UTILITY LOCATION CONFLICT Not Met Notice
Applicant 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 applicant's expense. Changes must be approved by the City in advance of work.Applicant shall coordinate the work
with affected utility agencies.
PFI_Utilities 14-TEMPORARY PATCH Not Met Notice
A temporary hard-surface patch shall be placed on trenches within roadways at the end of each work shift. Obtain advance
approval of patching method. No trench shall be left at any time in an un-safe condition. Applicant is responsible for and is
liable for hazards or damage resulting from the prosecution of the work.
PFI_Utilities 15-REPAIR OF EXISTING FACILITIES Not Met Notice
Work under this permit shall include repair of existing facilities(roads, ditches,etc.)as may be necessary, as determined by
the Inspector,to overcome deterioration or damage which occurred in conjunction with the work authorized by the permit.
Corrective work shall be done at the applicant's expense.
PFI_Utilities 16-PRECONSTRUCTION MEETING Not Met Notice
Before initiating any construction activity,the applicant shall coordinate with the City's inspector, <Insert Name>at<Insert
Phone#>,to establish a preconstruction meeting.
PFI_Utilities 17-NOTICE TO COMMENCE WORK Not Met Notice
The applicant shall notify the City's Inspector twenty-four(24)hours prior to commencing work, prior to any staged
inspection,and after completing work covered by the permit.
\Kenny Fisher at 503-816-6146
PFI_Utilities 18-PERMIT/PLAN ON SITE Not Met Notice
A copy of the permit including a Certificate of Insurance, and all attachments, and a copy of the approved construction plan
and all amendments shall be readily 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 these must be approved by the City, in advance of work
performance.
PFI_Utilities 19--MONUMENT PROTECTION Not Met Notice
Existing monuments, property corners, and survey markers shall be protected. Replacement shall be at the permit holder's
expense.
PFI_Utilities 20-EMERGENCY CONTACTS Not Met Notice
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 any emergency. The
applicant shall notify the City Inspector, in writing, of any/all assignment changes.
PFI_Utilities 21 -OTHER Not Met Notice
• RECEIVED
City of Tigard FEB 2 9 2016
� GARD PGE WORK ORDER# M1636868
= PUBLIC WORKS —E ���INEERING
Public Facility Improvement (PFI) Permit
DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL
Check one: 8 Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS
Detailed description: FOR SIDEWALK INFILL TIGARD PROJECT (] Minor work in right-of-way
(sidewalk repair,curb cut,street
RELOCATE ANCHOR &DOWN GUY. RAISING A VAULT LIT TO MATCH opening,etc.)requires:
FUTURE GRADE •Application form,completed
and signed
•Submit one(1)copy of scaled sketch
Property address/location(s): SW NORTH DAKOTA AND SW of the proposed work to be done
GREENBURG RD _: •Submit one(1)copy of traffic
control plan
S3 S
–OR–
Applicant's name: TOD SHATTUCK/TSAHAI ANDERSON E) Substantial project work requires
PP above items and professional
Address: 10800 SW AVERY STREET engineered plans for:
TUALATIN, OR 97062 •Street widening
City/state: Zip: •Subdivision infrastructure
Phone: 503-672-5466 Email: T&DSUPPORTAVERY@PGN.COM •Main utility line extension:
- Storm Drain,Sanitary—Tigard
- Water—Tigard Water Service
Contractor's name: CITY OF TIGARD CONTRACTOR Area(includes Durham,King City
CCB#: Expiration: and a portion of unincorporated
Washington County)
Address:
City/state: Zip: DELIVER APPLICATION TO:
City of Tigard
Phone: Email: Planning/Engineering
13125 SW Hall Blvd.
Engineer's name: JANE VAIL Tigard,OR 97223
Applications for"minor work in right-of-way"
Address: only may be emailed to:
City/state: Zip: ro rmitsngtigard-oLM
Phone: 360-852-9158 Email: JANE.VAIL@WALLISENG.NET
Case No.: / L�
Estimated value of work (within the public right-of-way): $
Application submittal 1�j�,
Is work related to a LAND-USE DECISION? ❑ Yes [J No Application accepted:,,
If so, please specify (MLP,SDR, SUB,etc.) case #: By: L-C-1. Date: 1�
Is work related to a BUILDING PERMIT? ❑ Yes 8 No Applicatio r ed:
By: Date:
If so,please specify(BUILDING PERMIT)case#:
�� l L 2
App. ant notified: 2
Wofk,, /\ o ti 1.4 ' ,��5 &30 ,,t-- 9^wt By Date: J
I CURPIN\Mastersland Use Appliratlons Rev.07/16/2014
ok- /b �- 'k. r o
City of Tigard 13125 SW Hall Blvd. Tigard,Oregon 97223 • www.tigard-or.gov 50 -718-2421 Page 1 of 4
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APPLICANTS
NOTE: Person specified as `Applicant" shall be designated"Permittee"and shall provide financial assurance for work.
*When the owner and the applicanf 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 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 each owner of the subject property required.
Digitally mg-d by TSANAI ANDERSON ////�'��� ////�'��� /��/�'++�
TSAHAI ANDERSON -2d1=TSA�1�ERSON@PGNGCOM, US TS�A�bAI AC1dVCSOCI 2/26/16
Dale 2016.02 26 06'51:13-08'00'
Applicant/Authorized Agent's signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
Cityof 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:
sIv ,. -s t
Edge of Pavement
I -40— Ditch
Streetlight — —r—'—
a Rain Drain
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1
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Scale: 1"=30'
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MINIMUM SKETCH REQUIREMENTS (Put'IN/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
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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a SERVICE COORDINATOR COMPANY
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'CURRENT SIDEWALK ANCHOR/BRACE a 503-323.6700 OR 503-46343/18(SALEM) IPH# :;a _-
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5022 OREGON LAW REQUIRES YOU TO FOLLOW RULES ADOPTED ,
40'4 143 40 T A 75 1808 BY THE OREGON UTILITY NOTIFICATION CENTER.
1966 THOSERULES ARE SET FORTH IN OAR 952-001-0010
THROUGH 952-001-0090 YOU MAY OBTAIN COPIES OF
THE RULES BY CALLING THE OREGON UTILITY
NOTIFICATION CENTER ADMINISTRATION d/(502-232-199
TO REQUEST UTILITY LOCATES CALL THE OREGON K1LaMr rrhet'e�I •
UTILITY NOTIFICATION CENTER,811 AT LEAST Call before you 11118
y 1 BUSINESS DAYS PRIOR TO EXCAVATION
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AS-BUILT VERIFICA 71ON8 NESC VIOLATIONS CORRECTED
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PGE General Foreman: Date:
SDPM,ENG REVIEW SBUILT SYDESIGNER:
GATE SCALE ACCOUM ANO JOB NO
Vicinity Map 2/22I2D16 1":25' 1070001 1000004546 M1636668
TITLE
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SER RIGHT-OF-WAY PERMIT NOTICE: ` PROGRESS-GREE NBURG 11x17
f- THINK APERMIT FROM THE LOCAL JURISDICTION IS REQUIRED BEFORE ANY
FOGE SW NORTH DAKOTA AND SW GREENBURG RG
L.AKv$9T P �G1 yWu, WORK IN THE RIGHT-OF-WAY MAYBE PERFORMED. ONLY PGE APPROVEDDESCRIPTION
SAFETY CONTRACTORS AND CONTRACTORS WHO HAVE MADE OTHER SPECIAL
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�'�`4+? •YN1�iy FIRST AGREEMENTS WITH PGE WILL BE ALLOWED TO WORK UNDER PGE'S PERMIT. COUNTY SECTIONS WO K WITH
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City of Tigard
April 28, 2016
PGE
Attn: Tsahai Anderson
10800 SW Avery St.
Tualatin, OR 97062
Re: Permit No. PFI2016-00034
Dear Applicant:
The City of Tigard has processed a refund for fees on the above referenced permit(s) as
follows:
Site Address: SEG535, North Dakota/Greenburg
Project Name: PGE
job No.: N/A
Refund: ® Check#220678 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$
Comments: Permit fee not required as this work is part of the CIP for sidewalks on 95`h
and North Dakota. Refund 100% of application fee.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Z64�A��
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. a 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 Request for PermitAction 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: PGE DATE: 3/31/2016
Attn: Tsahai Anderson
10800 SW Avery St REQUESTED BY: Dianna Howse
Tualatin, OR 97062 JH
TRANSACTION INFORMATION:
Receipt#: 402280 Case#: PFI2016-00034
Date: 3/1/2016 Address/Parcel: SEG535
North Dakota/Greenburg
Pay Method: CreditCard Project Name: PGE
EXPLANATION: Permit fee is not required as this work is part of the CIP for sidewalks on 951h and
North Dakota. Refund 100% of application 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
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 ONLY
Case Refund Processed: Date: 2 /gyp B
1:\Building\Refunds\RefundRequest.doc s 09/01/2010
0 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
w
Request for Permit Action
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
I'O: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
Came;(✓)(InL
REFUND OR Name:
INVOICE TO: (Businc,sorindividual)
oa..
Mailing Address: /0 8'0-a �K-)
City/State/Zip: 9 Too. Z
Phone No.: 3.(s-?-Z _6-qLLC.
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
❑ C
EL/VOID PERMIT APPLICATION.
nRPERMIT 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 #: PFT ,ZU 1 to — 0 0 3 4
Site Address or Parcel#: �ei, S-3 5-- Z"/^- f SGt)
Subdivision Name: / Lot #:
EX/P�NATION: ��,,-,n; cc rut 1- cviGk it wo,Wk A 4 o
-BG P "At- '4-
Signature: Date:
Print Name: ZZ
Rcfund Policy IV 41;f
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• kny 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. .ill 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 ONL)
Route to Sys_admin: Date B Route to Records: Date
Refund Processed: Date /(o B Invoice Processed: Date By
Permit Canceled: Date /{/ B arcel Tag.-added: I Date B
1:\Building\I-'orrns\ltcgPcrmit.\ction_092314.doc