PFI2016-00022 V 0
' City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT c//
= 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: flAAIA I O i/ 017Z 5
Phone No.:
PLE=CANCE
ACTION FOR THE ITEM(S) CHECKED (✓):
OID PERMIT APPLICATION.
D 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 ONPERMIT (do not cancel permit).
Permit#: PD 11Iio CVV 2 Z
Site Address or Parcel #: S ��
Subdivision Name: Lot #:
EXPLANATION: N hIyu -t du tic ml 1lv .
Signature: Date: ?>12311-)
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 pen-nit 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
Route to Sys Admin: Date By Route to Records: Date t/ /7 B
Refund Processed: Date B Invoice Processed: Date B
Permit Canceled: Date V-1 7 By Parcel Tag Added: Date B
I:\Building\Forms\RegPemiitAction_ 23l .doc
Agnes Kowacz
From: Kenny Fisher
Sent: Thursday, March 23, 2017 10:40 AM
To: Agnes Kowacz
Subject: FW: Question on PFI2016-00022
From: Chandler, Ivan [mailto:Ivan_Chandler@comcast.com]
Sent: Thursday, March 23, 2017 10:32 AM
To: Kenny Fisher
Subject: RE: Question on PFI2016-00022
Would it be possible to just cancel this one? We are having a bit of trouble with our contractors and they might not be
out there anytime soon. I do apologize for the trouble.
Ivan
Ivan Chandler
Construction Specialist 2 - Residential
11308 SW 68"' Parkway
Tigard, Oregon
97223
971-777-0908
From: Kenny Fisher [mailto:Kenny@tigard-or.gov]
Sent:Thursday, March 23, 2017 10:28 AM
To: Chandler, Ivan <Ivan Chandler@cable.comcast.com>
Cc: Agnes Kowacz<AgnesK@tigard-or.gov>
Subject: RE: Question on PF12016-00022
O k,
Our permit department was wondering. If this is the case and the job is still on the books can someone pick up
the permit so it will be in my hands and not sitting in the permit department? If not we can cancel it. Thank
you.
From: Chandler, Ivan [mailto:Ivan ChandlerCcbcomcast.com]
Sent: Thursday, March 23, 2017 10:14 AM
To: Kenny Fisher
Subject: Re: Question on PFI2016-00022
I will check into it here. Most likely the job has not started as of yet.
Ivan
Sent from my iPhone
On Mar 23, 2017, at 10:13 AM, Kenny Fisher<Kenny@tigard-or.gov>wrote:
Hello Ivan,
i
Our permit tech is asking about this permit as it was never issued and picked up. Was this
project ever completed?The work order number is 47894 at 14605 SW 88th Ave Tigard. It was
applied for on 2-17-2016 Thank You.
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."
2
V
V1791? leprflECEIVED
FEB 17 2016
CITY OF TIGARD
City of Tigard PLANNING/ENGINEERING
s: PUBLIC WORKS—ENGINEERING
Public Facility Improvement (PFI) Permit
DESCRIPTION OF WORK(in the right-of-way) TYPE OF WORK
Check one: 2 Utility Connection [TYPE 1—Franchise Utility Work
❑ Sidewalk/driveway approach Work performed by NWN,PGF
❑ Street improvements and/or utility agency.
Detailed description:43oGWe �,�2� 1'CLoy�t b�t7te� ❑ TYPE 2-Sidewalk/Driveway/Sewer
CA-TJ kf M0,5t,✓P-6 60—te n✓<t -TZ-, I AGX;' Work performed for the purpose of-
SW Ai>'O'Ayc TO Sidewalk installation or repair.
• Driveway approach installation
Property address/location(s): IL460ci -,-! N5-"-A<- and/or repair
I Cl 33 • Sanitary sewer lateral installation
and/or main fine tap
❑ TYPE 3—Full scale Development
Applicant: e-p"rasT Work performed with Iand use
Address: 'ae 5wnf(o a� 9A4-V-% A*`li approval which includes any of
ll- the following:
City/state:--SrzART�i. D&, 7ip:,9722.:5_ Subdivisions or Partitions
Phone:ft-777.090* Email:wAN-eLLAWLOXI'ru.•-t Street widening
Contact name: t vApd Phone: Mainline installation for Sanitary
sewer,Sturm sewer,Tigard water
Contractor: and/or Tigard Water Service Area
CCB#: ?0028 @ FAniration: 'I lZ,41'1 SUBMIT COMPLETED APPLICATION TO:
Address: lQlb S E P1"A 1G City of Tigard
City/state: l�"rtMSr W A. Zip:4N601 Planning/Engineering
z,2o1 Iimail:C.Ftrtfst?_dN•etnur6S 1Tig SW Hall Blvd.
Phone:'XW'335
Tigard,OR 97223
Contact name: LA"I Fosriet2 Phone: .applications 6x"minor work in right-of-way"
only may be emailed to:
Engineer:
Address:
City/state: 'Lip: r
Phone: Email: Case No.: FT U 16 ,r�' V 0 LZ
Contact name: Application submittal fee: 3420
Additional fees:
Estimated value of work is required(if over$5,000):$ Application�epced: 9
(within the public right-of-wap) By: Date:
/ Applica n e ewed:
Is work related to a LAND-USE DECISION% El Yes 1 J No
By. Date.
If so,please specify(MIT,SDR,SUB,etc.)case#:
/ Applicant Qotified:
Is work related to a BUILDING PERMIT? ❑ Yes e No By: ,.S Date: �Q
If so,please specify(BUILDING PERMIT)case#: '\VUKPLNnmt•nttMldUuAPOatt 11n07M/201s
City of Tigard 13125 SW Hall Blvd. Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page I 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 owners)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 that maybe attached to or imposed upon the subject proper
• 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 each owner of the subject property required.
� � �v_�f t sc4J-L'alt
Ap cant/Authorized Agent's signature Print name Date
Owner's signature Print name Date
Owners signature Print name Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SVC Hall Blvd. • Tigard,Oregon 97223 • www.rigard-or.gov • 503-718-2421 • Page 2 of 4
COMCAST
SPAN REPLACEMENT
14635 SW 88th AVE.
TIGARD, OR.
CONTACTS v SHEETINDEX
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11308 SW 68th PARKWAY
TIGARD, OR. 97223 3 GENERAL NOTES AND
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CELL 971-777-0908 SwMa„M��-„ �"a TYPICAL TRENCH DETAILS
ivan—chandler@cable.comcast.com _ 4 PLAN
LARRY FOSTER JOB SITE
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1910 SE 8th AVE
CAMAS WA. 98607 swv moo„ swona �` p
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L 19475 LEM, RD NE RNG: 1W SPAN REPLACEMENT $ SHT
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UTILITIES PH*
OR
PH: 971.600.0601 CALL LOCATE 2
FAX:971.275.1852 14635 SW 88th AVE BEFORE YOU
DAN DET DIG OF 4
nxutilities.com SCALE NONE DATE 2/16/2016 TGARD, OR.
REPLACE WITH MIN.
NATIVEGENERAL NOTES: REPLA TOPSOIL..
1. CALL UTILITY LOCATE AT all 72 HOURS PRIOR To TRENCHING OR DIGGING. RESTORE TO EXISTING 6" MIN. DEPTH OF 1"
CONDITIONS OR BETTER. DIA. CRUSHED ROCK
2. THE EXISTENCE AND LOCATION OF ANYFIUNDERGROUND INSPECTION
ION A RPES OR STRUCTURES
SHOWN ON THESE PIANS WERE OBTAINED BY FIELD ITUAL LICA AND A SEARCH OF THE ,{
AVAILABLE R CITY OR COUNTY RECORDS.SINCE THE ACTUAL LOCATION AND NATURE OF THE
UNDERGROUND FACILITIES MAY BE SOMEWHAT DIFFERENT FROM THAT SHOWN.THE ,,^aitil. N
CONTRACTOR IS REQUIRED To VERIFY PRIOR TO EXCAVATION. ro MAINTAIN 957
MAINTAIN 957 aS' COMPACTION OR
3. THE IS ASSUF-WAY SHOWN HIS NOT BEEN SURVEYED ON TED.RIGHT-OF-WAY COMPACTION OR GREATER & BACKFILL
LOCATION Is AssuMm WITH REFERENCE i0 ONLINE DATA SOURCE MATERIAL.CONTRACTOR GREATER do BACKFILL PER JURISDICTIONAL
TO VERIFY ALL RIGHTS-OF-WAY AND/OR EASEMENTS PRIM TO CONSTRUCTION. PER JURISDICTIONAL STANDARDS AND
STANDARDS AND 0
1. FOR UNDERGROUND ACTIVITY:TEST AND VENTILATE MANHOLE/UTIUTY VAULT PRIOR TO SPECIFICATIONS SPECIFICATIONS n
ENTRY,PLACE WARNING DEVICES ARD WORK AREA PROTECTION AS REWIRED,AND USE EYE
ANO HEAD SAFETY PROTECTION PER FEDERAL,STATE,AND LOCAL REGULATIONS.
6. ALL EXGAVATTON.TRENCHING.AND SHORING IS TO ADHERE TO THE CODE OF FmERAL PROPOSED PROPOSED
RFCI.TIONS(FR1 19 6651 SUBPART P SDR-11 R-11
PROVIDE ALL PRS WITH 1',1'SLOPE AT ONE END OF EXCAVATION FOR TECHNICIAN $D
INGRESS/EGRESS.
b. EXCAVATED SPOILS ARE TO BE NO LESS THAN 24'FROM EDGE OF PIT OR TRENCH. Q" MIN. BEDDING 4" MIN. BEDDING
BARRICADE ALL OPEN PITS AM TRENCHING FOR PUBLIC SAFETY.ALL BARRICADES
MUST BE EQUIPPED WRIT FLASHING LIGHTS FOR NIGHT VISIBILITY,
4. FOR PITS GREATER THAN 4'IN DEPTH,USE APPROPRIATE SHORING FOR WALL
STABILITY. TYPICAL TRENCH DETAIL TYPICAL TRENCH DETAIL
6. TRENCH COVER IS N BE 36'MINIMUM AND FREE OF ROCKS,DEBRIS.AND CLODS. UNIMPROVED AREAS
THE TRENCH IS TO BE A MINIMUM OF 36'COVER IN DEVELOPED AREAS AND A MINIMUM OF GRAVEL STREETS
4a.OF COVER IN UNDEVELOPED AREAS(ANY VARIANCE FROM THESE STANDARDS WILL BE NTS NT$
SPECIFIED ON THE PUNS).
7. ALL ASPHALT/CONCRETE AND LANDSCAPING REMOVED,DISTURBED.OR DAMAGED AS A
RESULT OF CONSTRUCTION SHALL BE RESTORED TO ORIGINAL CONDITION OR BETTER IN
ACCORDANCE WITH JURISDICnONAL AGENCY STANDARDS AND SPECIFK'ATIONS. SAWCUT EACH SIDE OF TRENCH
a. NORMAL/GUIDED-BORING METHOD RECOMMENDED WHEN BORING. WIDTH OF TRENCH — SAWCUT WIDTH
9. ADHERE TO AIRTIGHT GUIDELINES UNLESS OTHERWISE NOTED. REPLACE ASPHALT CONCRETE 6 12 6" 12" OR LESS 6" MIN.
PER JURISDICTIONAL � GREATER THAN 12" 12" MIN.
10. BOND BURIED/AERLIL FACILITES AS REQUIRED BY JURISDICTIONAL AGENCY(S). STANDARDS AND
11. AERIAL FACILITIES ARE TO BE TESTED PRIOR TO BEGINNING WORK PER STATE AND SPECIFICATIONS. 3" MIN.
A
LOCREGULATIONS.
12. ALL WORK AREA PROTECTIONS FOR TRAFFIC CONTROL IS TO BE WITH APPROVED
WARNING DEVICES AND PLACED PER STATE DEPARTMENT OF TRANSPORTATION AND/OR
PUBLIC WORKS ENGINEERING DEPARTMENT STANDARDS AND SPECIFICATIONS.IF REQUIRED.A MAINTAIN 957
TRAFFIC CONTROL PLAN SHALL BE SUBMITTED TO THE REQUESTING PERMITTING AGENCY, COMPACTION OR
PRIOR TO BEGINNING WORK,PERMITnNG AGENCIES MUST BE NOTIFIED 48 HOURS IN GREATER do BACKFILL
ADVANCE of CONSTRUCTION ACTIVITIES. GREATER
JURISDICTIONAL
13. EXISTING PEDESTRIAN CROSSWALKS AND WALKING AREAS SHALL BE MAINTAINED AT ALL STANDARDS AND
TIMES.AS NECESSARY.TEMPORARY PEDESTRIAN CROSSWALKS AND WALKING AREAS SHAY SPECIFICATIONS 10
10
BE PROVIDED AND MAINTAINED PER STATE DEPARTMENT OF TRANSPORTATION AND/OR PUBLIC
WORKS ENGINEERING DEPARTMENT STANDARDS AND SPECIFICATIONS.
14. THE FOLLOWING FOOTAGES ARE ESTIMATES.FOOTADES TO BE VERIFIED PRIOR TO PROPOSED
CONSTRUCTION.
SDR-11
4" MIN. BEDDING
NOTE TYPICAL TRENCH DETAIL
CONTRAOR CTORAGENTSMUENCROACH PROPERTY
WITHOUT NOTIFYING THE PROPERTOWER AMNIMOF -NMRRSS IINADVANOF ASPHALT SURFACE
ENTRY.NOTICE SHALL BE IN PERSON OR BY DOOR HANGER F OWNER IS NOT PRESENT AT
TIME OF PHYSI AL VISIT.DOOR HANGER SHALL NOTIFY PROPERTY OWNER OF THE NTS
CONTRACTOR'S NAME,PHONE NUMBER,AND NATURE OF ENCROACHMENT AND WORK TO BE
PERFORMED
TWN:2S
SEC 11 COMCAST DIAL W o 47894
1947 CLAXTER RD NE RNG: 1W 1
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ND UTILITIES PH: 971.600.0601 CALL LOCATE 3
FAX:971.275.1852 14635 SW 88th AVE BEFORE YOU
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FAX:971.275.1852 40 14635 SW 88th AVE BEFORE YOU
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