PFI2016-00048 April 28,2016 City of Tigard
Comcast Cable
Attn: Steven Loy
11308 SW 68'h Parkway
Tigard, OR 97223
Re: Permit No. PFI2016-00048
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: Adjacent to 11533 SW Hall Blvd
Project Name: Comcast
Job No.: N/A
Refund Method: ® Check #220646 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): Permit was created in error as work was performed in ODOT ROW
which requires a state permit. Refund 100%of application fee.
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 Requestfor Permit Action 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: Comcast Cable DATE: 3/31/2016
Attn: Steven Loy
11308 SW 68`h Parkway REQUESTED BY: Dianna Howse
Tigard, OR 97223 JH
TRANSACTION INFORMATION:
Receipt #: 402511 Case#: PFI2016-00048
Date: 3/14/2016 Address/Parcel: Adjacent 11533 SW Hall Blvd.
Pay Method: CreditCard Project Name: Comcast
EXPLANATION: Permit created in error as the work being performed is in ODOT ROW(requires state
permit). 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: SIGN URES 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: m By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
. r
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0
Request for Permit Action 3/3'
13125 SNX' I Tall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.g_ov
TO: 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 JR City Staff
Chcck(✓)nn,
REFUND OR Name:
INVOICE TO: (Business or Individual) Cf WL
Mailing Address: 11309 su) G 8*�- PA�kii-A,
City/State/Zip: Aar 0(L l �j�-Z23
Phone No.: 21 "to , 3 ell
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 #: PFI-2-01U — ox tle
Site Address or Parcel#: I t T-S3
Subdivision Name: Lot#:
PLAN TIO
Signature: Date: 312-42-01L,
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 ITSE ONLY
Route to Sys.-Admin: Date BV Route to Records: Date By
Refund Processed: Date B Invoice Processed: Date B
Permit Canceled: Date3 3i /{o B T Parcel Tag Added: I Date BN-
1:\Building;\f,'orms\RcgPermitAction_0923 4.doc
CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
a COMMUNITY DEVELOPMENT Permit#: PF12016-00048
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 03/14/2016
Parcel: SEG788
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Comcast
Project Description: Adjacent to 11533 SW Hall Blvd.,place new 2"schedule 40 pipe with CAN mainline in ROW from PGE
pole 20' N to driveway entry to 11515. Trench will be hand dug 36"deep.
Owner: FEES
Description Date Amount
PFI Permit Fee 03/14/2016 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
KEN PARRIS
11308 SW 68TH PKWY.
TIGARD, OR 97223
PHONE: 503-596-3811
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
Signature: Not Present
Issued By: ---�-
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12016-00048
Type: Condition Name: Status: Severity:
PFI_Utilities 01 -WORK SITE REQUIREMENTS Applied 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 02-WORK SITE AREA Applied 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 Applied 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 Applied 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 Applied 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 Applied 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 Applied 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 Applied 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 Applied 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 Applied 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 11 -TRAFFIC CONTROL MODIFICATION Applied 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 Applied 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 Applied 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 Applied 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 Applied 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 Applied 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 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 Applied 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 Applied 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 Applied 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 Applied Notice
RECEIVED
City of Tigard MAR 0 3 2016
PUBLIC WORKS — ENGINEERING CITY OF TIGARD
P NING/EWGINEERING
Public Facility Improvement (PFI) ` ermit
DESCRIPTION OF WORK(in the right-of-way) TYPE OF WORK
Check one: X Utility Connection X TYPE 1—Franchise Utility Work
£ Sidewalk/driveway approach Work performed by NWN,PGE
Street improvements and/or utility agency.
Detailed description: Place new 2" schedule 40 pipe with CAN mainline £ TYPE 2—Sidewalk/Driveway/Sewer
in ROW from PGE pole 20ft N to driveway entry to 11515. Trench will be hand dug Work performed for the purpose of:
36" deep a Sidewalk installation or repair.
• Driveway approach installation
Property address/location(s): work is in front of 11533 SW Hall blvd and/or repair
e Sanitary sewer lateral installation
and/or main line tap
£ TYPE 3—Full scale Development
Applicant: Comcast Cable Work performed with Land use
approval which includes any of
Address: 11308 SW 68th Parkway the following:
City/state: Tigard OR ZIP: 97223 • Subdivisions or Partitions
Phone: 503 596-3754 Email: kenneth_parris@cable.comcast.com • Street widening
Contact name: Ken Parris Phone: 503 596-3811 • Mainline installation for Sanitary
sewer,Storm sewer,Tigard water
Contractor: Fisk Communication Contracting INC. and/or Tigard Water Service Area
CCB#: 185632 Expiration: 2/24/2017 SUBMIT COMPLETED APPLICATION TO:
Address: 2705 NE 65th ave City of Tigard
City/state: Vancouver WA Zip: 98661 Plsssisg/Pagiarrrsag
Phone: 360 984-6567 Email: fcckris@gmail.com 13125 SW Hall Blvd.
Tigard,OR 97223
Contact name: Kris Raimer Phone: 360 989-7285 Applications for"minor work in right-of-way'
ordy may be emailed to:
Engineer: w_"ermits jjgaard-or.gov
Address:
City/state: Zip: •R STAFF USE ONLY
�-•
Phone: Email: Case No.: PIF 17-O 16"cobH
Contact name: Application submittal fee: goo
Additional fees:
Estimated value of work is required(if over$5,000):$ Applic ccepted:
(within the public right-of-way) By: Date: 313
Applicad n r 'ewed:
Is work related to a LAND-USE DECISION? £ Yes £ No 3 !I 2011<
By: Date:
If so, please specify (MLP,SDR, SUB,etc.) case #: Applicant notif ed:
Is work related to a BUILDING PERMIT? £ Yes £ No By: LS Date:
If so,please specify(BUILDING PERMIT)case#• 1:\CURPLN\Masters\Land Use Applicat ons Rev.07/09/2015
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 a wwwtigard-or.gov e 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 arc 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 anti,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 orized Agent's signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
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City of Tigard 13125 SW Hall Blvd. • Tigard,Oregon 9'1223 • www.tigard-or.gov 5113-71$-2421 • Page 2 of 4
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