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PFI2015-00054 • OV 0 City of Tigard COMMUNITY DEVELOPMENT DEPARTMENT { Request for Permit Action flfll� 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 Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: 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#: ��/ �1:� exx)S Site Address or Parcel#: Project Name: (�¢g Subdivision Name: Lot#: EXPLA ATION: i i" Signature: Date: 61,2(C-11 Print Name: Refund Policy 1. '11he 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 809/6 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 B Route to Records: Date B Refund Processed: Date ff- B Invoice Processed: Date B Permit Canceled: Date %6V,, B arcel Tag Added: Date B 1:\Building\Forms\RegPemiitAction_0 2314.doc CMCX - -"I' 0 1 City of Tigard V RECEIV�b APR 2 3 2015 PUBLIC WORKS ENGINEERING �` Public Facility Improvement (PFJ)A9'0&2tEMRING DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL Check one: W Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS Detailed description: From existing pole,trench 13' (SE)to right of way ❑ Minor work in right-of-way (sidewalk repair,curb cut,street a Min of 36" depth, placing (1)-2" conduit. opening,etc.)requires: •Application form,completed and signed •Submit one(1)copy of scaled sketch Property address/location(s): 10830 SW Greenburg Rd,Tigard, OR 97223 of the proposed work to be done •Submit one(1)copy of traffic T control plan —OR— A OR— Applicant's name: Comcast Attn: Ken Parris E] Substantial project work requires PP above items and professional Address: 11308 SW 68th Parkway engineered plans for: Tigard 97223 •Street widening City/state: g Zip: •Subdivision infrastructure Phone: 503-596-3811 Email: Kenneth_Parris@cable.comcast.com •Main utility line extension: Storm Drain,Sanitary–Tigard - Water–Tigard Water Service Contractor's name: Fisk Communications Area(includes Durham,King City CCB#: 185632 Expiration: 02/24/17 and a portion of unincorporated Address: 2705 NE 65th Ave Washington County) City/state: Vancouver, WA Zip: 98661 DELIVER APPLICATION TO: 360-314-4454 fccsteve@comcast.net City of Tigard Phone: Email: @ 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: rermitsC_tigard-or.gov Phone: Email: FOR STAFF USE ONLY J" Estimated value of work (within the public right-of-way): $�� Case No.: 0a)5J U x`300 Application submittal fee: Is work related to a LAND-USE DECISION? ❑ Yes 8 No Applica'on accepted: _ If so,please specify (MLP, SDR, SUB, etc.) case #: By: S Date: �S Is work related to a BUILDING PERMIT? ❑ Yes © No Application reviewed: ztS If so,please specify(BUILDING PERMIT)case#: By: A-9 Date: �' 2' Applicant notified: �— By: Date: I:\CURPLN\Masters\Land Use Applications Rev.07/16/2014 Cityof 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 hat 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 ch o ner of the subject property required. Plica n thorized 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 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: s I,V Z- t Edge of Pavement I -44— Ditch —40 �y Streetlight I •—•—•—•------- —r—•— TI R.D��, 1 ' T—'P'ropos d"5e1werTine'— � I 1 N� Existing House Existing >1 Driveway c0- 01 I W rl o� m I p+o > T o ' Existing Shop � Powerrpole I 0 0 --------76pertyLine—-—-—-—-—- � I ' I II Fire Hydrant(FH) � � I Scale: 'I"=30' � I I 1 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 City of Tigard - 13125 SW Hall Blvd. - Tigard,Oregon 97223 - www.tigard-or.gov - 503-718-2421 - Page 4 of 4