PFI2016-00109 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT o
Request for Permit Action
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
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 ® City Staff
Chcck(✓)one
REFUND OR Name: N/A
INVOICE TO: (Business or Individual)
Mailing Address: N/A
City/State/Zip: N/A
Phone No.: N/A
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 #: PFI2016-00109
Site Address or Parcel#: 15445 SW 150`h Ave.
Project Name: NW Natural
Subdivision Name: N/A Lot#: N/A
EXPLANATION: Per Kenny Fisher in Engineering, this ROW is not under City of Tigard's
jurisdiction. Please void.
Signature: > Date: 5/25/16
Print Name: Lina Smith
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
• ' OFFICE USE ONLY
Route to Sys Admin: Date J lig Route to Records: IDate, /b B
Refund Processed: Date IV
I B Invoice Processed: Date B
Permit Canceled: Date fes, A0 I B Parcel Tag Added: Date B
I:\Building\Forms\RegPermitAction_ 923] .doc
14
V RECEIVED
City of Tigard S17,-c,/fry MAY 2 3 2016
PUBLIC \X'ORKS — l,NGINIi1:RING CITY OFTIGARD
s G/ GINEERNVG
Public Facility Improvement (� errnit
DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL
Check one: 8 Utilities ❑ Sideustllc/dm evcay approach ❑ Street improvements. ELEMENTS
Replaced 2'of 2" main due to damage. ❑ Jlinor aYirk in right-of-a-ay
Detailed description: P �) 9e• _
(sidewalk repair,curb cut,street
The main us is on the 26' in ROW under earth. No hard surface opening,etc.)recluires:
cut was needed. The damage location was 10' S of Hawk Ridge Rd. •Application form,completed
and signed
•Submit one(1)copy of scaled sketch
Property address/location(s): 15445 SW 150th Ave of the proposed work to be done
WR#3460881 •Submit one(1)copy of traffic
control plan
–OR–
A ficant's name: NW Natural/Judith Randle ❑ Substantial pmiect work requires
PP above items and professional
Address: 220 NW 2nd Ave engineered plans for:
Portland OR 97209 •Street%widening
Cit'/State: /.tp: •Subdilklision uifrastructure
Phone: 503/2264211 x4334 F.mai1:12r@nwnatural.com •Main utilit-line extension:
- Storm Drain,Sanitary—Tigard
LO Clark/JiFitzgibbon - eater—Tigard Water Ser%ice
Contractor's name: Loy m 9 Area(includes Durham,ting Cin
CCB#: 52281 I xpiration: and a portion of unincorporated
Address:
PO Box 1369 Washington County)
Cit•/state: Tualatin OR Zip: 97062 DELIVER APPLICATION TO:
503/644-2137 Jim.fitz ibbon to clark.com
City of Tigard
Phone: 1?mail: 9 G Y Planning/Engineering
13125 SW Hall Blvd.
Engineer's name:
Andrea kuehnel Tigard,OR 97223
220 NW 2nd Ave Applications for"mitxx work ut right-of-way"
Address: onh•mai'be entailed to:
City/state: Portland OR Zip. 97209 rax i w card-0r�ov
Phone: 971/409-7594 Finail: Andrea.kuehnel@nwnatural.com
Estimated value of work (within the public right-of-.vat-):S case No.: -6I
Application submittal. fee:
Is work related to a LAND-USI`. DI:CISION? ❑ Yes ❑ No Application accepted: )�
If so,please specify (XILR SDR,SUB,etc.) case #: 13v: 5 Date:�tE'
Is work related to a BUILDING PER.\IIT? El Yes ❑ to Application r
nerved:
If so,please specify(BUILDING 1111LNi11)case#: By: Date:
Applicant noti A:
�Jr9 15 NAA t►�'Tia►tti �i ���s�.� .
� By- 6 — Date:
4:NCUWV4%MWtMuAW USe AppkaMm RM trat/oi+
Cityof Tigard • 13121 S\X*l tall Blvd. Tiprd,Oregon(r227) • .vwwrigard-or.fg,)%- • i0.i 718-2421 • Page l of 4
APPLICANTS
NOTE: Person specified as`Applicant"shall be designated"Permittee"and shall provide financial assurance for work.
When the caner atxl the applicant are different people,the applicant must be the purchaser of record or a lessee it possession aith tt7;pen
authorization front the owner or an agrnt of the(Ywtter. 'Ilse oaner(s)nutst sign this application in the space prm i&d or sttbtttit a&-rittett
authorisation with flus apptiutiote
BY SIGNING BELOW,1'HE APPLICANT(S)SHALL CEKfIFY I-HA1':
• The above request does not violate anN deed rec ric ionc thatma)-be attached to or imp d u n die c t jcct pa4=
• If the application is granted,the applicant will exercise the rights granted in accordance uvith 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 anv such
statements are false.
• 'Ilne 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.
Judith Randle 05/21/2016
��PPlicant/':lurhoriicd :A��ent's sit)tlature Print Marne I),tte
C�vvner s signature Print name Date
Owner's signature Print name Date
Owners signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City Of Tigard • 13125 Ste'Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-orgov 303-718-2421 • Page 2 of 4
14
DEVELOPMENT ENGINEERING FEES
1. Public Facility Improvement (PFI) Permit:
Put 1: Required submittal fee$1300.00
Put 2: All non-x,.ater system improvements
Engineer's estimate X 5%Qess 5300.00 submittal fee)
Engineer's estimate X 2%Plan Review
Put 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 SVX'Hall Blvd. Tit and, Oregon 97221 Nra-n•.t1gard-nr.gov :103-718-2421 • Page 3 of 4
SAMPLE SKETCH:
Edge of Pavement
I -*— Ditch moi*
Streetlight I — -------•-----C—'—
Rain Dmin
I '
1 I .ten\f 3 O 1
I I , •
T'imi'd
W I I N� I 1►� I 4 Existing House
Existing 1
Driveway
3� I
ii 1
O,
VIa l rr��
V1
I i
01 j Existing Shop
J I
Powerpole I I 2
I
�. o • o
I I a 95'
------�---
I -----�ropeTjiLine
I I O
1
II Fire Hydrant(FH)
I ITT I
Scale: 1"=30'
I I
I !
i I I
i � I
MINIMUM SKETCH REQUIREMENTS (Put"N/A"if Not Applicable):
North arrow Property lines& dimension Slope of propert
Street&street name(s) I:xisting building,structures Utility& street light poles
Proposed work Existing curb or edge Trees
Existing SAX'or of pavement Existing utility locations
DAV apron (scxver,water,storm)
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard - 13125 SW Hall Blvd. - Tigard,Oregon 97223 - u-%v\%:tigard-or.go%- - 503-718-2421 - Page 4 of 4
Lina Smith
From: Randle, Judith <Judith.Randle@nwnatural.com>
Sent: Saturday, May 21, 2016 3:10 PM
To: ROW Permits
Subject: NW Natural Damage Permit Request WR#3460881
Attachments: 15445 SW 150th Ave Tigard_permit.pdf; 15445 SW 150th Ave Damage Sketch.pdf
Categories: Routed for Eng. Review
We are reviewing a back log of Damages that had not been permitted. We are working to bring these permits current.
Sorry for the delay.
Thank you,
Judith Randle
NW Natural Gas Co
Engineering Dept
J2r@nwnatural.com
503/226-4211 x4334
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