PFI2017-00025 TapCity of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 1--*�
Request for Permit Action x
13125 SW Hall Blvd. •&M 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: 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 ITEMS) CHECKED (✓):
Q
��D
L OID PERMIT APPLICATION.
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#: PFI2017-00025
Site Address or Parcel #: SEG444
Project Name: PGE
Subdivision Name: N/A Lot #: N/A
EXPLANATION: Per Engineering, this PFI permit is not required. The work has already been
included under the Hall Pointe Townhomes PFI permit.
Date: 2/21/2017
Signature: �--
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE ITSE ONLV
Route to Sys Admin: I Date B� Route to Records: Date 3'Ad//7 1B
Refund Processed: Date ft B Invoice Processed: Date B
Permit Canceled: Date 3110117/7 B Parcel Ta Added: Date B
I:\Building\Forms\RegPermitAction_0 231 .doc
V ® 1 D RECEIVED
31/,01-7 _AY_ FEB S 1 2017
City of Tigard
CITY OF TIGARD
PUBLIC WORKS — ENGINEF,RING PLANNING/ENGINEERING
Public F acihty Improvement (PFI) Permit
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
TYPE 1—Franchise L;tilir}'Work
Check one: Utilities ElSidewalk/driveway approach ElStreetnmprovements performed by NWN, PGF,
Detailed description: PGE JOB M2012402 and/or utility agent},.
INSTALL SVC TO 3 BLDG 14 TOWN HOUSE ❑ TYPE 2—Sidewalk/Driveway/Sewer
Work performed for the purpose of:
• Sidewalk installation or repair.
8716 SW SPRUCE ST,TIGARD 97223 • Driveway approach installation
Property address/locatiron(s): and/or repair
Sir • Sanitary sewer lateral installation
and/or main line tap
Applicant: PORTLAND GENERAL ELECTRIC El TYPE 3—Full scale Development
PP 10800 SW AVERY STREET Work performed with Land use
Address: approval which includes any of
Ci TUALATIN,OR 97062 the followin
. t}/state: Lip: 8:
Phone: 503-951-3714 Email: PREREQCOORD@PGN.COM • Subdivisions or Partitions
Contact Warne:
DUMITRU ILIOI Phone: • Street widening
• Mainline installation for Sanitary
Contractor: N/A sewer, Storm sewer,Tigard water
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 wclrk in right-ofway"
Engineer: DUMITRU ILIOI only may be emailed to:
Address:
10800 SW AVERY STREET Ln=mutsQtigard-or.aov
TUALATIN,OR Zip: 97062
City/state:
Phone: 503-951-3714 Email: PREREQCOORD@PGN.COM Case No.: PFao11-C)00Z5
Contact name: .Application submittal fee:$
-Additional fees:$
Estimated Value of work is required(if over$5,000):$ Application accepted:
(within the public right-of-way) By: Al�__ Date: Z Z I
Is work related to a L AND-L?SE DECISION? El ❑ No Application rettiewed:
If so,please specify (MIA"SDR,SUIS,etc.) case#:
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes ❑ No By: Date.
If so,please specify(BUILDING PERMI'I)case#: 1.ytHG\ft- •l�\Pt-6PPW~ ft�12/16/7016
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-ocgov • 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.
Vith the exception of a utility operatvtg pursuant to a valid franchise with the Oty of'[igard,when the owner and the applicant arc different
people,the applicant mutt be the purchaser of record or a lessee in possession with written authorization from the owner or an agent of die
owner. The owner(s)must sign this application in the space provided 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 APPLICANT(S) SHALL CERTIFY THAT:
• The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject
propern
• if the application is granted,the applicant will exercise the rights granted in accordance arith 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.
L— -7-—t*.1b43 plock's—
Applicant/Aur orized Agent's signature Print name Date
SIGNATURES of each owner of the subject property, if required.
Owner's signature Print name Date
Owner's signature Print natne Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SAY'I lallBh•d. • Tigard,Oregon 97223 • w•wwtigard-or.gov • 503-718-2421 • Page 2 of 4
DEVELOPMENT ENGINEERING FEES FO R STAFF U SE ON LY
Public Facility Improvement(PFI)Permit:
DETAILED SUBMITTAL
APPLICATION FEE REQUIREMENTS
Part 1: Requited submittal fee$30o.00
FRANCHISE UTILITY AND SIDEWALK/
PERMIT FEE DRIVEWAY AND UTILITY
Part 2: All non-water system improvements CONNECTIONS,ETC.
Engineer's estimate X 5%(less$300.00 submittal fee) (work in the right of way)
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',,o ❑ Site Address
PFI Permit Fee Exemptions: FULL SCALE DEVELOPMENT
There will be no pernut 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. (G 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 he 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
City of Tigard 13125 SWI call Blvd. • Tigard,Oregon 97223 • uwwtigard-or gov • 503-715-2421 • Page 3 of 4
SAMPLE SKETCH:
jEdge of Pavement
Ditch —♦"
Streetlight ( —•—•--------- —r---
1 °• R.a.rrati
r a
� 1
' T—'p'i3�os cl"'Se1w'er'Tiiie" �
CL)
Ni Existing House
a� 1 Existing
Driveway
Cd
ad
v� I
b.l
I i
TT�� 011 I
J1
0
� Existing Shop �
J � 1
Powerpole I I d
�► o • o
I a 95'
1
I1 Fire Hydrant(FH)
� I I
Scale: 1"=30'
� � I
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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/Vi'or of pavement Existing utility locations
D/W apron (sewer,.eater,storm)
PUBLIC FACILITY IMPROVEMENT PERMIT
Cit}of Tigard • 13125 SWI call Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 4 of 4
M#R4 VAULT WffH 3'TERAB-DUCTS H I.' D.Ee CONTACT PGE
ifP°EI" w,rAHSFDeREe F.a FOR APPROVED
MANUFACTURERS SUBDIVISION LEGEND
�r�` — 1 NEW PGE FACILITIES TO BE INSTALLED
(UNLESS OTHERWISE SPECIFIED)
.�,��,I \ 0 ..:ems '.•�•,• F
w,Rx.cu d1/-PGE IAOMOIJM VAUIT,WRN 6/-332P-2Q5-PGE TOP
C U 'F• O PROVIDED 8 INSTALLED BY CUSTOMER
gICT3 BDM EMM) •.•, • �. � S S�,S
!, O •: _ •'•'•�:' :,. RR{'ti;S• M"OH O TTJO SECONDARY VAULT,CA
0 -rCal411a •.::M• ��'' �� PROVIDED&INSTALLED BY CUSTOMER
e ImMMv- oMn TOP NEW
r/ TSN / • W� PIL O FAULT INDICATOR
/'rJ IIT•' i'Mw aIRRRs oY v Dlm suit wE
INSTALL CUTOUT
sr LT V WE FUSING AS NOTED
ALL SKONDMY VAULTS(0,30)TO BE INSTALLED ON PROPERTY LINES WITHIN THE UTILITY EASEMENT
TRENCX DETAL'A' T AND AT FINAL GRADE.ALTERNATE LOCATIONS MUST BE APPROVED BY PGE AND WILL BE NOTED
IsfCONf1MV_aREOrSIh ON THE SKETCH,
THECOST FOR RELOCATION OR ADJUSTMENT OF A 7 3 VAULT WILL BE THE RESPONSIBILITY OF 12"PVC CONDUIT FOR FUTURE,(OR GOLD TEMP).
MEBUILDER OR DEVELOPER REOUESTRIG THE MOVE.TGE APIROVAIS OF INSTALLATION WILL BE BASED PROVIDED&INSTALLED BY CUSTOMER
ON FINAL GRADE AND LOCATION CRITERIA SET BY INE DEVELOPER AND HIS OR HER AGENT.
---------INSTAR 1-#2 AL-EPR JKT PRIMARY IN 1-2'WC CONDUIT
- 3± TInIT ATT!' O I FRONDED&INSTALLED BY CUSTOMER
-400AM '
INSTALL 1-9350 AL-TX SECONDARY IN 2 OF--CONDUIT
r PD 30 OA 1111 SWAMP
PKR 45-4 5934 I BE...."�,;:0 �i PROVIDED&INSTALLED BY CUSTOMER
!11, I, -------- INSTALL L-49 AL-TX SECONDARY IN 1-3"PVC CONDUIT
11 21,957A AFC 1987 I I PROVIDED&INSTALLED BY CUSTOMER
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I CONSTRUCTION NOTES: RSDEv
` I. cusroMEe ro nroLmE nENCHIrLe.Fw sFnI1Ne.nlErt USE TRENCHF
SYnN�E.IRENfH ro BE 4.INCHES DEET NCNfs—MEASURED ROM
'A 2 ALL TGE CONOUCIORf TO Bf INSTALLED IN—Y,SORDULE.0,ELECIRIGt
m.RroP� ME.
M CONDDIT— Br 1H. 500 165.rz3T).
TGE TO DRF _TM_ANDF M[R p C°Nd1IIS epM[o.
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AND 2.HOIIDprtu nICXEs CIFAYNCE EFMTE
II Rvar.,
IIADE M&SMNIER i0,BE 36 IFECTI
1 I C 1 ' NL BENDS MUST BE fARORY MADE
AU ALL FRONS(AGER THAN I INCH i0 BF
III nx, 60 INCH RADIUS.RIGID STFFL OR TGE AIIROND FIBlIIGIASf B[NDS ME REQUIRED
11 qe RUNS d SI FFfI(„L1OSDNGIDU t M KfbS RFT FM I—
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—OFE
11 150 rtFT OAR NESS THE�IMUM TOi IENDs Rl °NDUII RUN GHES
11 CLSgMER R6gNSbIE PoR ROAD CIIOSSR9GS.ALL QOSSINGS MIST EKRNO
11 INF ro rROMR E.UTE—1 GAY,_DIRE.D.
11 3 ELFCTRK NRGRMF�n<CONDUT.cRO551Ncs ro BE u ttXHEi DEET.A.E.-
1.12
EASURED
11 FROM FNIAI GARDE.
i i 210' WR CHECKLIST .Ern H RIN A QUIRE"E.`NI e K„ s17.qEY T YL NEI oExT
1 I ITEM YES COMMENT ' oe scHFDUUF°o P c W" c l Cooi:N{cT1GioN((C RTAS of uiF MECH.Fneu
CONNEC ODUCR M AN iFRR"RAllvf ro HDVE DUCT E vlAu MEET THE
A 23 7956 1 yr Iso / _. IalmecER RF—I i ENT, FSA En a°eEAiDIFnLcA_ LD o309s"A(.Y.uc-RRE_'auuly sr roJEo
Boom x o i°v vi REREoMr— HouiwwT�roRr C M -.1riixEMFcro�. 11ENH rtn of
$W SPRUCE ST POHOEExX $.cusroMER TD—AND
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1 umm vuaT Mone oR fouvuear wR ro[TAD MRDurT IRAreFoeAEEa.
1 rADVAAT To BE SEI AT FBJ.RL GRADE DEE DEIN ON,S.'",
M 4 CU 1 AB 2 ACSR qE TRA RS FD BE INSTuI�B FEET(MIN)FRDM coEAsusmlE
e.Au ovERHANG AND. ARE
350' • _. _ LOCATES IGF WEf fORMERf MUSI.—..—.FA--
STA" BF WITHIN S F[ET('O AF M�IE�LXYORN".
O --... STADNG uw•rs MAINnW a rtEr<UARANCE IN FRONT W ua TRANSFORAIDIS.
O` fUGGNG ],ro BARRIfII g51S Mf MOURNED MOUND iILwSPoRMERS nAl Mf EaOSfD
5933 1.ALL SNITCH VAULTS TO BE SA AT FINAL GRADE W m I INCH GRAVEL MSE AND
45=4 5932SFf DF NIµ SKETCH)
FN fR THE VAULT END I—RNOCKd 5 ERM 40U I5).
1932 45'- EASEMENT FRONT LOT MLK u R D FA DRAM n.E.)D BE B FEET,IM,M,
1980 PERMITS q FEET PRENRRfa).
TRAFFE FUN a.nn SFOiMFR Lo i"c VSFptMTAGF uaculfORATIw+sL�MR o ON 5 icw
O P - 50 B PHASE '""T" rcR RFSIOENCE. m rms c°NFFRENCE
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THINK R eNCNBFDMNN
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1P 7.2 2420 PM IOOKVA NTLB
DSAFETY SMIIOAYH IT DESIGN G 6Mf0°"STANDARp IhWfR Al AH AD FC�°
\ ON 644-PGE PADMOUNT VAULT 5 E�EHEw.G rw —MAY BE
FIR3T1 DooR XM10D
CONTACT
C ANY CONSTRUCTION DRAWING
INA co AS-BUILT VERIFICATION & NESC VIOLATIONS CORRECTED
DATE Aw TAH dlx .Dn—1,Ee9 .-FIELD Ce.m ..
Fom DaN:
FL-mu CONTACT SERVICE COORDINATOR Genemi FOmmo Date:
Foe WENCH SET
roHwn InncrroE.naR RIGA-0F-WAY PEP NOTICE: n. S'noh•m on uimd FoT field Ca ftchon changes.)
INSTALL 2'POLE CONDUIT UNIT ro McanL PVE cru DoT w�*uL wDF SDPA4ENG REVIEW: BUILT BY DESIGNER:
WITH I2'BRACKETS,1-742 GO F65T uMn EN.. n eM< uED A PERMIT FROM THE LOCAL JURISDICTION 15 REQUIRED BEFORE AM
SERVICE COORDINATOR WORK IN THE RIGHT-0F-WAY MAY BE PERFORMED. ONLY PGE APPROVED DAM 2117 SGUE:"S ACCOUNT:ro]0001 —'1000004597 —M=2102
& I IGHT" ARRESTER 5013}33700,OR 5033633IUB(SMfi" CONTRACTORS AND CONTRACTORS WHO HAVE MME OTHER SPECIAL
AGREEMENTS VATH TGE WILL BE ALLOWED TO WORK UNDER ME'S PERMIT. irltF
fS
I THE MR MUST NOTIFY THE LOCAL JURISDICTION 18 HOURS HALL POINTE TOWNHOMES
I•�'Yt BEFORE RT WORK IS TO BEGIN.A COPY OF THE PERMIT MUST BE ON SITE, DREWE57 PORTLAND-NORTH s717R22
ANY DEVIATION FROM THIS DESIGN MUST CALL 817 BEFORE YOU DIG PGE/ I--
NO.- TTENTION:
BE APPROVED BY PGE PROTECT MANAGER EGON LAW REQL/NES YOU W PouoW RULES ADOPTED 1, 8735 SW SPRUCE ST,TIGARD
BY THE OREGON UTILITY NOTIFICATION CENTER DESa1rTIDFT
B-- FACILITIES NOT DRAWN TO SCALE THOSE RULES ARE SET FORTH IN OM 952-001-0010 INSTALL PH 120240V UG SERVICE TO NEW 14 LOT SUBDIVISION
H
THIS DRAWING B A GRAPHICAL REPMENTA77ON Of Pg1Tl.MI/D GENERAL THROUGH 952-0040090.YOU MAY OBTAIN COMES OF EnIONIS, RK WIT
ELECTRIC FACIlIf1E5 IN THE fIE1D.THIS MN RLUSTRATES ELECIRICAL TME RULES W CALLING THE ORFOON UTIIJTI' WASH CO CIL-35A
CONNECTMIY,TYPES AND NUMBERS OF CONDUCTORS AND PLACEMEN OF N011fICA1pN CENRR AGNRNSibMTON® E503-7u-Mn NE cREw cEHRRG, rHONE(yp3) DuwN
EQUIPMENT WITHIN THE DISTRIBUTION SYSTEM.IT IS RECOMMENDED THAT :I REQUEST UTILITY LOCATES CALL THE OREGON F. w1aYs LYBIOW. DUMRRU IUOI 672-5177 DUMRRU IUOI
THE USER NOT RELY ON THIS DIAGRAM FOR GEOGRARHICAL LOCATIONS UTILITY NOTIFICATION CENTER 817 AT IFAfi SII 6elore 6 M___'l .mw
2 BUSINESS DAYS PRIOR TO EXCAVATION. TW IB O MINT1AND GENERAL ELECTRIC CO-All.RIGHTS RESERVED