PFI2016-00258 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
■
Request for Permit Action /.2/4;t�'O
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: 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 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 #: PFI2016-00258
Site Address or Parcel#: SEG791
Project Name: NW Natural
Subdivision Name: N/A Lot #: N/A
EXPLANATION: Per Engineering,permit is not required for work because it is located on a
private street.
Signature: ..-1_ �:� Date: 11/30/16
Print Name: Lina Smith
Rcfund 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
• ' OFFICE USE ONLY
Route to Sys Admin: Date li% Route to Records: Date/.A/Z�V76 I B
Refund Processed: Date B Invoice Processed: Date IB
Permit Canceled: Date By arcel Tag Added: Date B
I:\BLiilding\Forms\ReqPeffriitAction—O9Ml4.doc
RECEIVED
City of Tigard V 0 1 m! NOV 2 g 2016
PUBLIC WORKS — ENGINEERING r�/��/��P
�1TY 01:TIGARD
Public Facility Improvement (PFI) Permit',EERI"G
DESCRIPTION OF WORK(in the right-of-way) TYPE OF WORK
Check one: E Utility Connection
[j] TYPE 1—Franchise Utility Work
❑ Sidewalk/driveway approach Work performed by NWN,PGE
❑ Street improvements and/or utility agency.
Detailed description: Install new long side 1/2"(P)service. Main is on the ❑ TYPE 2—Sidewalk/Driveway/Sewer
1'in PUE inside property on East side of street. Possible cut over other Work performed for the purpose of:
utilities. WO#: 3488817 • Sidewalk installation or repair.
• Driveway approach installation
Property address/location(s): 9719 SW London Ct and/or repair
SI • Sanitary sewer lateral installation
and/or main line tap
❑ TYPE 3—Full scale Development
Applicant: NW Natural/Shelly Kirschenman Work performed with Land use
Address: 220 NW 2nd Ave approval which includes any of
the following:
City/state: Portland OR Zip: 97209 • Subdivisions or Partitions
Phone: 503-226-4211 x4347 Email: smk@nwnatural.com • Street widening
Contact name: Shelly Kirchenman Phone: 503-226-4211 x4347 • Mainline installation for Sanitary
sewer,Storm sewer,Tigard water
Contractor: Loy Clark/Jim Fitzgibbon and/or Tigard Water Service Area
CCB#: 52281 Expiration: SUBMIT COMPLETED APPLICATION TO:
Address: PO Box 1369 City of Tigard
City/state: Tualatin OR Zip: 97062 Planning/Engineering
503-644-2137 im.fitz ibbon to clark.com 13125 SW Hall Blvd.
Phone: Email:1 9 @ Y Tigard,OR 97223
Contact name: Jim Fitzgibbon Phone: 503-644-2137
Applications for"minor work in right-of-way"
only may be emailed to:
Engineer: Peter Cathcart ro ermits .tigard-or.eov
Address: Same
City/state: Zip:
Phone: 503-715-7441 Email: PlC@nwnatural.com Case No.:PFI201(0- W15
Contact name: Application submittal fee: •d
Additional fees:
Estimated value of work is required(if over$5,000):$ Application accepted:
(within the public right-of-way) By: ZOL Date: Z�
Is work related to a LAND-USE DECISION? ❑ Yes ❑ No Application reviewed:
By:JG-:5 t, Date:
If so, please specify (MLP, SDR, SUB, etc.) case #:
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes ❑ No By: Date: �O
If so,please specify(BUILDING PERMIT)case#: l:\cURPLN\Masters\Lana use Applications Rev.07/09/2015
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.
*IX7hen 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 APPLICANTS) SHALL CERTIFY THAT:
• The above request does not violate any deed restrictions ha 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 each owner of the subject property required.
Digitally signed by Shelly Kirschenman Shelly
�
DN:cn=Shelly Kirschenman,wn USN Natural, _\h e I I y Kirschenman 11/23/2016
ou,email=smk@natural.com, US V
Date:2016.09.30 14:58:34-07'00'
Applicant/Authorized 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 FOR STAFF VSIONLY
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 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:
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(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 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
City of Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 3 of 4
SAMPLE SKETCH:
Y
Edge of Pavement
Ditch
Streetlight I ,------------- —C---
Rain Dnin
r1
a
>.> 1
1 6
I I II� j
T--Frd–P d�5�3�fiiR�"
�1 Existing House
I Existi n
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CI w I ' jry•
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Al
Al' I I
.V i
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0
Existing Shop �
L I
Powerpole
I I� 95,
yT•�-------7rropertyLine----- --
I I
II Fire Hydrant(FH)
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Scale: 1"=30'
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MINIMUM SKETCH REQUIREMENTS (Put`IN/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
WO#: 3488817
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NW Natural PLAT:1-042-019 COUNTY:WASHINGTON LTJ 11/23/16 17:0
(503)226-4211 TOWNSHIP:T01S RANGE:R01W SECTION:35SW SCALE:1 IN=100 FT USER ID:smk
2011 Edition Page 85
Stationary Lane Closure with Flagging Diagram 320
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Sign Spacing and Buffer Lengths(feet) 1 1 w
Posted Spacing Between Signs Buffer W
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Speed A B C Space t sd
20 50 I O
25 100 100 100 75
30 10035 125 Ne
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40 350 350 350 150 2 9
45 180 3
50 500 500 500 210
55 250
December 2011 Chapter 5
Page 84 2011 Edition
Stationary Lane Closure with Flagging Diagram 320
Diagram 320 covers total closure of one lane of a two-lane, two-way
roadway. See the detail inset for the layout if using a single flagger to control
both directions of traffic on low volume roads (less than 400 ADT)with good
sight distance as discussed below.
1. Use truck-mounted flashing warning lights on work and protection
vehicles. See Section 4.3— Lights and Lighted Signs for exceptions.
2. For added visibility, a truck-mounted arrow board or PCMS in caution
mode may be used.
3. Flaggers at each approach are required if any of the following
conditions exist:
a. Night Operations.
b. Work space is over 200 feet in length.
c. Sight distance is less than 750 feet from each approach
through the lane closure.
d. Traffic volumes are greater than 400 ADT.
4. The length between the Flagger Ahead signs shall not exceed one
mile. Use Diagram 340— Lane Closure with Pilot Car if exceeding one
mile.
5. Cones should be used to outline the work space when curves or other
roadway alignments prevent clear direction for the motorists to pass
the work space safely.
6. Cones along the work space are recommended when posted speeds
are 45 mph or greater, when working under heavy traffic or when travel
lanes are narrower than 11 feet.
7. Extended queue signing (see Diagram 5-4)should be used when
traffic queues extend beyond the initial advance warning sign.
8. When flagging near an intersection, the "Flagger Ahead" (CW23-2)
sign should be visible to traffic entering from any side road. Additional
advance warning and Flagger Ahead symbol signs may be placed on
the side road(s).
9. Sign set-up and flagger placement shown may be used for intermittent
full road closures of 20 minutes or less.
10. The"ONE LANE ROAD AHEAD"(W20-4) sign is optional and should
be considered on high volume or high speed roads, or when extended
queues are expected.
Chapter 5 December 2011