PFI2016-00271 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
x
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
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEMS) 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#: IP-T-ti 2-mo'CYD-2;1
Site Address or Parcel#: S cc g
Project Name:
Subdivision Name: Lot #:
EXPLANATION: D(A PLA46 Pf fl Lc : (J-C- {� ( 2-0(12— QQ ZCZ7
Signature: Date: TI(1
Print Name: S �OIn�Gt C 2
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 USE ONLY
Route to Sys Admin: Date B% Route to Records: Date Y117117 I B
Refund Processed: Date N l f- B Invoice Processed: Date B
Permit Canceled: I Date B Parcel Tag Added: Date B
I:\Building\Forms\RegPexmitAction_ 923 4.doc
Agnes Kowacz
From: Agnes Kowacz
Sent: Tuesday, April 4, 2017 6:20 AM
To: 'Pam Baldwin'
Subject: RE: NEW REQUEST City of Tigard permit application, 6917 SW OAK, PGE JOB M2049032
Attachments: SKM_C554e17040406160.pdf
Hi Pam-
As we talked on the phone, attached is your permit PF12016-00257. We are going to void PF12016-00271 as this is a
duplicate of PF12016-00257. Please see attached permit.Thanks!
Agnes
From: Pam Baldwin [mailto:Pam.Baldwin@pgn.com]
Sent: Monday, April 3, 2017 1:53 PM
To: Agnes Kowacz <AgnesK@tigard-or.gov>
Subject: RE: NEW REQUEST City of Tigard permit application, 6917 SW OAK, PGE JOB M2049032
I'm sorry Agnes if I call you now will you be available? O
From: Agnes Kowacz [ma iIto:AgnesK(Ptigard-or.gov]
Sent: Monday, April 03, 2017 9:30 AM
To: Pam Baldwin
Subject: RE: NEW REQUEST City of Tigard permit application, 6917 SW OAK, PGE JOB M2049032
***Please take care when opening links, attachments or responding to this email as it originated
outside of PGE.***
Hi Pam, give me a call when you have a moment. Thanks!
503-718-2421
Agnes
From: Pam Baldwin [mailto:Pam.Baldwin@pgn.com]
Sent: Monday, March 27, 2017 8:41 AM
To: Agnes Kowacz<AgnesK@tigard-or.gov>
Subject: RE: NEW REQUEST City of Tigard permit application, 6917 SW OAK, PGE JOB M2049032
Hi there.....Attached is the permit from December that we received! O
From: Agnes Kowacz [mailto:AgnesK@a tigard-or.gov]
Sent: Monday, March 27, 2017 8:29 AM
To: Pam Baldwin
Subject: RE: NEW REQUEST City of Tigard permit application, 6917 SW OAK, PGE JOB M2049032
***Please take care when opening links, attachments or responding to this email as it originated
outside of PGE.***
Will do. O What is the permit number that covered the work (the permit you go in December)?Thanks!
From: Pam Baldwin [mailto:Pam.Baldwin@pgn.com]
Sent: Monday, March 27, 2017 8:22 AM
1
To:Agnes Kowacz <AgnesK@tigard-or.gov>
Subject: RE: NEW REQUEST City of Tigard permit application, 6917 SW OAK, PGE JOB M2049032
Thanks Agnes, Yes please cancel this one as we already have the approved permit from December. O
From: Agnes Kowacz [mailto:AgnesKCcbtigard-or.gov]
Sent: Monday, March 27, 2017 6:13 AM
To: Pam Baldwin
Cc: Chris Jewett
Subject: RE: NEW REQUEST City of Tigard permit application, 6917 SW OAK, PGE JOB M2049032
***Please take care when opening links, attachments or responding to this email as it originated
outside of PGE.***
Hi Pam-
I am not sure either, it was sitting in our inbox from a while ago. I am assuming that it was a duplicate permit (which is
not uncommon). We can cancel this one, I just need your approval to cancel/void it. Thanks,
Agnes Kowacz I Associate Planner
City of Tigard I Community Development
13125 SW Hall Boulevard
Tigard, Oregon 97223
Phone: 503.718.2429
Email: AgnesK@tigard-or.gov
From: Pam Baldwin [mailto:Pam.Baldwin@pgn.com]
Sent:Thursday, March 23, 2017 2:07 PM
To: Agnes Kowacz<AgnesK@tigard-or.gov>
Cc: Chris Jewett<Chris.Jewett@pgn.com>
Subject: FW: NEW REQUEST City of Tigard permit application, 6917 SW OAK, PGE JOB M2049032
Hi Agnes,
This permit was sent to me in December 2016. We have already received it for PGE Job M2049032. Not sure why we
are getting two?
Thank you,
Pam Baldwin —Prerequisite Line Coordination
Portland General Electric
10800 SW Avery St.,Tualatin,OR 97062
W: (503)612-6107 1�: (503)612-6150 I ®pam.baldwin(a�pgn.com
From: Agnes Kowacz [mailto:AgnesKC&ti ard-or.gov]
Sent: Thursday, March 23, 2017 9:12 AM
To: Prereq Coord; ROW Permits
Cc: Chris Jewett
Subject: RE: NEW REQUEST City of Tigard permit application, 6917 SW OAK, PGE JOB M2049032
***Please take care when opening links, attachments or responding to this email as it originated
outside of PGE.***
Attached is your approved permit.Thanks,
2
Agnes Kowacz I Associate Planner
City of Tigard I Community Development
13125 SW Hall Boulevard
Tigard, Oregon 97223
Phone: 503.718.2429
Email:AgnesK@tigard-or.gov
From: Pam Baldwin [mailto:Pam.Baldwin@pgn.com] On Behalf Of Prereq Coord
Sent:Tuesday, November 22, 2016 2:29 PM
To: ROW Permits<rowpermits@tigard-or.gov>
Cc:Chris Jewett<Chris.Jewett@pgn.com>; Prereq Coord <PreregCoord@pgn.com>
Subject: NEW REQUEST City of Tigard permit application, 6917 SW OAK, PGE JOB M22049032
Good afternoon,
Attached is the City of Tigard permit application,job sketch and TCP for PGE Job M2049032.
If you have additional questions please contact Chris Jewett at 503-672-5481.
Thank you,
Pam Baldwin—Prerequisite Line Coordination
Portland General Electric
10800 SW Avery St.,Tualatin,OR 97062
2: (503)612-61071 8:(503)612-6150 1 ®pam.baldv in(a)pgn.com
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."
3
� v
CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
s COMMUNITY DEVELOPMENT Permit#: PF12016-00271
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 12/22/2016
Parcel: SEG268
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: PGE
Project Description: Adjacent to 6917 SW Oak Street. Underground existing 0/H to correct voltage problem. PGE Job
M2049032.
Owner: FEES
Description Date Amount
PHONE
Contractor:
PHONE:
FAX:
Applicant:
CHRIS JEWETT
10800 SW AVERY STREET
TUALATIN, OR 97062
PHONE: 503-672-5481
Tota 1 $0.00
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:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12016-00271
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 Applied 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. call Ken fisher at 503-816-6146 or Kenny@tigard-or.gov
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 o.f Tigard DEC 19 2016
C PUBLIC WORKS —ENGINEERING CITY OF TIGARD
Public Fadh tY Improvement (PF1)PPNeTN`fGINEERING
1
TYPE OF WORK
DESCRIPTION OF WORK(in the tight-of-way)
TYPE 1—Franchise Utility Work
Check one: Vutilioes ❑Sidewalk/driveway approach ❑Street improvements performed by NWN, PGE
Detailed description: PGE JOB M2049032 and/or utility agency.
Underground Existing O/H to Correct Voltage Problem. ❑ TYPE 2–Sidewallc/Driveway/Sewer
Work performed for the purpose of:
• Sidewalk installation or repair.
6917 SW Oak, Tigard, OR 97223 • Driveway approach installation
Property address/locadon(s): and/or repair
B • Sanitary sewer lateral installation
and/or main line tap
Applicant: Portland General Electric ❑ TYPE 3—Full scale Development
PP Work performed with Land use
Address: 10800 SW Avery St. approval which includes any of
City/state: Tualatin, OR Zip: 97062 the following:
Phone: 503-672-5481 Email: PreregCoord@pgn.com - Subdivisions or Partitions
Contact name: Chris Jewett Phone: 503-672-5481 • Street widening
• Mainline installation for Sanitary
sewer, Storm sewer,Tigard water
Contractor: NIA and/or Tigard Water Service Area
CCB#- Expiration:
Address: SUBMIT COMPLETED APPLICATION TO:
City/state: Zip: City of Tigard
Phone: Email: Planning/Engineering
13125 SW Hall Blvd.
Contact name: Phone: Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: Chris Jewett only may be emailed to:
Address:
10800 SW Avery St. ro rmits .tiQard-or.gov
City/state: Tualatin, OR Zip: 97062 rn
Phone: 503-672-5481 Email: Prereq .00rdQpgn.com Case
Contact name: Chris Jewett Application submittal fee.
Additional fees:
Estimated value of work is required(if over$5,000):$ Application accepted:
(within the public right-of-way) By: IV: Date:
Application reviewed:
Is work related to a LAND-USE DECISION? ❑ Yes N(No
•.S 1'L
If so,please specify (MLP,SDR,SUB,etc.) case#: By: � Date: 1Z
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes VNo By: 7�7& Date:
If so,please specify(BUILDING PERMIT)case#: 1.\CURPLN\Msner&%Land UmAppR bob Rev.09/26/2016
r.. .-r.:... . .:._.,:.a:. -..> --, .-..... -.y.•:..iv... sa......esn:.—w— — .—
City of Tigard • 13125 SW 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,if
required by the city pursuant to TMC 15.041.140.
With the exception of a utility operating pursuant to a valid franchise with die City of"Tigard,when the owner and the applicant are different
people,die 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 prodded or submit a written authorization with this application. Franchised
Utilities are not required to obtain the owner's signature on the application
BY SIGNING BELOW,THE APPLICANTS) SHALL CERTIFY THAT:
• The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject
r r .
• If the application is granted,the applicant will exercise the tights 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 any 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.
Brian Moore 11/22/16
Applicant/Aut orized Agent's signature Print name
Date
SIGNATURES of each owner of the subject property,if required.
Owner's signature Print name Date
Owners signature Print name Date
Owners signature Print natne Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov 503-718-2421 Page 2 of 4
DEVELOPMENT ENGINEERING FEES
Public Facility Improvement(PFI)Permit:
APPLICATION FEE
Part 1: Required submittal fee$300.00
FRANCHISE UTILITY AND SIDEWALK/
PERMIT FEE DRIVEWAY AND UTILITY
CONNECTIONS,ETC.
Part 2: All non-water system 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 system improvements ❑ Street Name
Engineer's estimate X 12% ❑ Site Address
PFI Permit Fee Exemptions: FULL SCALE DEVELOPMENT
There will be no permit fee charged,or assurance required
(Subdivisions/Partitions and Street Improvements)
for the following types of work:
• 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)
• Weep hole repair ❑ Cover—Site,Vicinity,Abbreviation,Legend
• Curb repair or replacement(less than 20 lineal feet) ❑ General Notes(City,Water,Sewer,etc)
• Lawn sprinkler system installation or repair ❑ Street(Plan,Profile)
• Street tree pruning or planting ❑ Water,Storm and Sanitary(Plan Profile)
• Planter strip landscape maintenance ❑ Water Quality Facilities
• Test wells ❑ Grading
❑ Landscaping/Tree Plan
❑ Composite Utility Plan(Electrical,Phone,Gas,
Note: A cash assurance may be 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 SW liall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 3 of 4
SAMPLE SKETCH:
Edge of Pavement
I -* — Ditch
Streetlight I ---•_•—•—•—•— —r---
A �nna,
I �o 0 1
' i'�iopos d"Selw'eiT'ine"
CL) I
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,�� g House
z� I Existing
: Driveway
al 0i 1
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-E
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� J
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� � I
Scale: 1"=30'
� I I
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MINIMUM SKETCH REQUIREMENTS(Put"N/A"if Not Applicable):
Nordi 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,stonn)
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW 11all Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov - 503-718-2421 Page 4 of 4
2011 Edition Page 85
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WR CHECKLIST
ATTENTION. CALL 811 BEFORE YOU DIG
I
OREGON LAW REQUIRES YOU TO FOLLOW RULES ADOPTEDBYTHEOREGON UTILITY NOTIFICATION CENTERTHOSE RULES ARE SET FORTH IN OAR 951-001-0010THROUGH 951-001-0090 YOU MAY OBTAIN COPIES OF
THERULES BY CALLING THE OREGON UTILITY PGE CONSTRUCTION DRAWING
NOTIFICATION CENTER ADMINISTRATION 0(502-132-1987) -BUIL 1 A I NBNE` .. ED
TO REQUEST UTILITY LOCATES CALL THE OREGON V—avAet-.hP)�• T,,, . , ,,,,,„-UTILITY NOTIFICATION CENTER,811 AT LEAST Calibeft YOUdk} Foreman: Date2 BUSINESS DAYS PRIOR TO EXCAVATION General Foreman: DateW Ra41 mea/nFlpn Chin
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