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PFI2015-00130 ' City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT1 Request for Permit Action , .r, t , - 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 TigardBuildingPermit @tigard-or.gov FROM: ❑ Owner ❑ Applicant E] Contractor City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) T Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): CANCE *0113 PERMIT APPLICATION. ND 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#: P F 2.0 I S- 00136 Site Address or Parcel#: T( 51 r, S W � � A—, Project Name: Subdivision Name: Lot#: EXPLANATION: -e m C , i Signature: Date: 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 OFF ICE USE ONLY Route to Sys Admin: Date By Route to Records: Date /C1 /S B Refund Processed: Date /✓ B Invoice Processed: Date B Permit Canceled: Date ti B arcel Tag Added: Date B I:\Bading\Foffns\ReqPemiitAction-091314.doc Betsy Ruef From: Tricia Wolfe <Tricia @clogbustersllc.com> Sent: Tuesday, September 15, 2015 11:59 AM To: Betsy Ruef Subject: Re: PFI Application Hi Betsy...it looks like I will no longer be in need of the Right of Way permit for 14575 SW 88th in Tigard. Thank you so much for all of your help! Tricia Wolfe Owner Clog Busters LLC Cell (503) 730-9775 Office (503)680-8947 V www.clogbusterslic.com www.facebook.com/cloqbustersllc www.yelp.com/biz/clog-busters-IIc-hilIsboro On Sep 14, 2015, at 2:46 PM, Tricia Wolfe <tricia(c-Mogbustersllc.com> wrote: <Public_Facility_Improvement_Permit copy.pdf> Please let me know if I've forgotten anything! Thank you Betsy! Tricia Wolfe Owner Clog Busters LLC Cell (503) 730-9775 Office (503)680-8947 1 <clog busters new improved logo copy.png> www.clogbustersllc.com www.facebook.com/clogbustersllc www.yelp.com/biz/clo.q-busters-Ilc-hillsboro On Sep 14,2015, at 1:44 PM, Betsy Ruef<BetsyGati arq d-or..g_ov>wrote: Tricia, Attached is our PFI Application please complete and submit for review. Thank you, Betsy Ruef Permit Technician Assistant City of Tigard I Community Development 13125 SW Hall Blvd Tigard, OR 97223 DISCLAIMER: E-mails sent or received by City of Tigard employees are subject to public record laws. If requested e-mail may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law E-mails are retained by the City of Tigard in compliance with the Oregon Administrative Rules "City General Records Retention Schedule.` <Public_Facility_lmprovement_Permit.pdf> 2 VvE® City of Tigardcd' ' `EC1 ENGINEERING PUBLIC WORKS — SEP 1 / 4 2015 = ty Improvement Public Facili rovement (PF;�11?V*rRING p DESCRIPTION OF WORK (in the right-of-way) TYPE OF WORK Check one:,Utility Connection xlp� PE l—Franchise Utility Work ❑ Sidewalk/driveway approachE J`►Q 1"1 33 Work performed by NWN,PGE El Street improvements ` and/or utility agency. Detailed description: F_X NcaR 1'1011•_ ne_Y:E 'j.-3 1'$))&e El TYPE 2—Sidewalk/Driveway/Sewer C r\d J2 TCCLt lc - V QI-C Irl P)4- t7F (~ '�-`r l Jr1Q \ ork performed for the purpose of: -I t) fr-� � PQS i-}IVP L Q i n P G+1 dYl "+n 44nC! • Sidewalk installation or repair. }� `Q,�r�, • Driveway approach installation . I and/or repair Property address/location(s): /1+--t S Z S S w 25 $4--h &-.Ie- . Sanitary sewer lateral installation and/or main line tap S W �i t''2sb r'pQIL ❑ TYPE 3—Full scale Development Applicant: 0.1M B us+e"rS Work performed with Land use S approval which includes any of Address: 2_216(f SW r� a`S 1, C1 the following- City/state: I Zip: 7 • Subdivisions or Partitions Phone�t73—Co�C�ail. i Gi • Street widening Contact name: \ r;C-�Cl $O I+-*C Phone. 9 L/7 • Mainline installation for Sanitary sewer,Storm sewer,Tigard water Contractor: 1✓ CSS CI 42 je I i C,Ckz\ft— and/or Tigard\Fater Service Area CCB#: Expiration: SUBMIT COMPLETED APPLICATION TO: Address: City of Tigard City/state: Zip: Planning/Engineering 13125 SW Hall Blvd. Phone: Email: Tigard,OR 97223 Contact name: Phone: Applications for"mu)or work in fight-of-way" only may be emailed to: Engineer: r�gerrnitsjkfig&d-or.Dov Address: City/state: Zip: Phone: Email: Case No.: RU ZOO S' 00130 Contact name: Application submittal fee: Additional fees: Estimated value of work is required(if over$5,000):$�,OQ O Application accepted: (within the public right-of-way) By: 2>-X Date: �S Application reviewed: Is work related to a LAND-USE DECISION? El Yes Q(No Bir.� Date: If so, please specific (MLP, SDR, SUB,etc.) case #: Applicant notified: Is work related to a BUILDING PERMIT? ❑ Yes ❑ No B}- Date: If so,please specify(BUILDING PERMIT)case#: 1:\CURPLN\M•stem\L"Use Apoksbom R•v.07/09/2015 City of Tigard 13125 SVG'Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-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. T1te 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 ani,deed restrictions that mai•be attached to or imposed upon the subject Prroopt . • 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 anv 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 ut ' ed 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 • wwu:tigard-or.gov 503-718-2421 • Page 2 of 4 14575 SW 88th Ave 14S i 6 SW 88t-Ave Street Vies, Search^e3rbY O 14511 e � • `r SO 3 CAyF-I ion pipe %-> I voxel OIA wy� 00 b .0 4Dt0 \M\iSTRtK1ipM •M� r .1-1 r f`....»4.. rw.T. 0.i..+».• r.n»�wn.MyrL 7r.r.. DEVELOPMENT ENGINEERING FEES 1:01t STAFFUSE, ONLY Public Facility Improvement (PFI)Permit: DETAILED SUBMITTAL APPLICATION FEE REQUIREMENTS Part 1: Required submittal fee$300.00 FRANCHISE UTILITY AND SIDEWALK/ PERMIT FEE DRIVEWAY AND UTILITY CONNECTIONS,ETC. Part 2: All non-water sv stem improvements (work in the right of way) Engineer's estimate X 5% (less$300.00 submittal fee) Engineer's estimate X 2%Plan Review Sketch Including information below) WATER SYSTEM FEE ❑ Dimensions Part 3: All public water s}stem improvements ❑ Street Name Engineer's estimate X 12% ❑ Site Address PFI Permit Fee Exemptions: There will be no permit fee charged,or assurance required FULL SCALE DEVELOPMENT for the following types of work: (Subdivisions/Partitions and Street Improvements) • Sidewalk repair(less than 20 lineal feet) • Relocate or replace mailbox Design Plans • Ditch cleaning that does not involve regrading. (6 sets,24x36 or 22x34) • Weephole repair ❑ Cover—Site,Vicinity,Abbreviation,Legend • Curb repair or replacement(less than 20 lineal feet) ❑ General Notes(Cita;Water,Sewer,etc.) • Lawn sprinkler system installation or repair ❑ Street(Plan,Profile) • Street tree pruning or planting ❑ Cuter,Storm and Sanitary(Plan Profile) • Planter strip landscape maintenance ❑ Cuter Quality Facilities • Test wells ❑ Grading ❑ Landscaping/Tree Plan ❑ Composite Utility Plan(Electrical,Phone,Gas, Note: A cash assurance maybe required per Storm,Sanitary,Water,Signage,Street Lights,etc) TMC 15.04.140.(customer deposit) ❑ Details ❑ Traffic Sight Distance ❑ Signing and striping ❑ Street Light Plan and Photometric ❑ Engineers seal/signature ❑ Sheet label(project land use name,revision and plan log block,dates and sheet numbers.) Additional Submittals (per Land Use conditions) ❑ Traffic Report ❑ Storm water Drainage Calculations ❑ Geotechnical Report ❑ Preliminary Access Report(Sight Distance) ❑ Proposed Plat ❑ Pathway Design(if applicable) ❑ Water Department Approval PUBLIC FACILITY IMPROVEMENT PERMIT Cityof Tigard 13125 Soh Hall Blvd. • Tigard,Oregon 97223 • w a,%vtigard-or.gov • 503-718-2421 • Page 3 of 4 8600,& 0 14 0 % �01 ss 11 ao + 70 J 14590 bo SS 11A 038 _Q S 11-A041 d 5 w �j 8655 IL_ —w 1 r- co 40 14 ao �,�/'"� SS11Q042-"1 8935 b0 1 8710 SS11a037 P I N E B R O O K ST ISSIIA039 sSIIA040% 8870 840 Ll t Foe. i �c ! SAMPLE SKETCH: Edge of Pavement I "Q — Ditch StreetlightI -- ----------- —C--- I e �� r , i e I ' i—MMETP' d^Se1werTine" IN II i5 Existing House Existing �i Driveway I - z. (L 0 I o a "I I >� I o Existing Shop i Powerpole I I Y CD Q 1 I�-------17op95—ne------- ----- � I ' I I I Fire Hydrant(FH) � � I Scale: 'I"=30' � 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 City of Tigard - 13125 SW Hall Blvd. - Tigard,Oregon 97223 - www.tigard-or.gov - 503-718-2421 • Page 4 of 4