PFI2016-00212 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V n
= p Request for Permit Action 11/7/40 ,
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#: Fn 4 ZD�I(6J�-[pr-Iop 2l Z"r n
Site Address or Parcel#: 0 1� y RA11 1j10
Project Name: P G_F-"
Subdivision Name: Lot#:
EXPLANATION: -�r r<e44ed UWT icAtt-tlw-
Signature: Date: (7 W
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 OFFICE USE ONLY
Route to Sys Admin: Date 1i� Route to Records: Date 111711(o(o B
Refund Processed: Date Alle By Invoice Processed: Date B
Permit Canceled: Date / / By
—Parcel Ta Added: Date B
I:\Building\Fomes\RegPemvtAction_ 23 4.doc
Agnes Kowacz
From: Agnes Kowacz
Sent: Monday, September 26, 2016 10:44 AM
To: Prereq Coord; ROW Permits
Cc: Dumitru Ilioi; Brian Moore
Subject: RE: City of Tigard permit application, 15456 SW HALL BLVD, PGE JOB M2077859
A permit from the City of Tigard is not required as this is ODOT right of way. Please contact ODOT for approval. Thanks,
Agnes Kowacz I Associate Planner
City of Tigard I Community Development
13125 SW Hall Boulevard
Tigard, Oregon 97223
Phone: 503.718.2429
Email: APnesK@tigard-or.gov
From: Pam Baldwin [mailto:Pam.Baldwin@pgn.com] On Behalf Of Prereq Coord
Sent: Friday, September 23, 2016 8:16 AM
To: ROW Permits<rowpermits@tigard-or.gov>
Cc: Dumitru Ilioi <Dumitru.11ioi@pgn.com>; Brian Moore <Brian.Moore@pgn.com>; Prereq Coord
<PreregCoord@pgn.com>
Subject: City of Tigard permit application, 15456 SW HALL BLVD, PGE JOB M2077859
Good morning,
Attached is the City of Tigard permit application and job sketch for PGE Job M2077859.
If you have additional questions please contact the project manager, Dumitru Ilioi at 503-672-5477.
Thank you,
Pam Baldwin—Prerequisite Line Coordination
Portland General Electric
10800 SW Avery St.,Tualatin,OR 97062
GY: (503)612-61071 (503)612-6150 pam.baldvinCd)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."
1
RECEIVED
SEP 2 6 2016
City of'Tigard CITYOFPLANNING ENGINEERING
_ TIGARD
PUBLIC \VORKS —ENGINEERING
Public Facility Improvement (PFI) Permit
REQUIRED SUBMITTAL
DESCRIPTION OF WORK(in the right-of-Nvay) ELEMENTS/
Check one: 1�Public utilities(gas lune,electric,data cable) P<1 inor work in right-of-way
❑ Sidewalk/driveway approach and utilities only (sidewalk repair,curb cut,streer
❑ Street improvements opening,etc.)requires:
rr •Application form,completed
Detailed description: ���� r 3��� and signed
1-4" BORE ACROSS HALL Bl_VD •Submit wo(2)copies of scaled
sketch of the proposed work to be
done
*no sve,&-.St2,3S qc-,on file kjq qXUyms voeQlj.^/ •Submit two(2)copies
Property address/location(s): of traffic control plan
�S� �JJr _L54�M SW Hall Blvd, Tigard, OR 97224 —OR—
PArc464( WO, ❑ Substantial project work requires
above items and professional
Applicant's name: Portland General Electric engineered plans for:
•Street widening
Address: 10800 SW Avery Street •Subdivision infrastructure
City/state: Tualatin,OR Zip: 97062 •Main utility line extension:
Storm Drain,Sanitary—Tigard-
Phone: Email: PreregCoord@pgn.com Water—Tigard Water Service Area
Contactperson: Dumitru Ilioi Phone: 503-672-5477
Contractor's name:
CCB#: Expiration: DELIVER APPLICATION TO:
Address: City of Tigard
City/state: Zip: Planning/Engineering
Phone: Email: 13125 SW Hall Blvd.
Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer's name: only may be einailed to:
Address: ronazermits(a).tigard-or.gov
City/state: Zip: FOR STAFFUSE ONLY
Phone: En><til: �p� .��y
24
Case No.�T J0-002'1Z—
Application submittal fee:
Estimated value of work is required(if over$p5,000):$ Application accepted:
(within the public right-of-way) By: h11d-' Date: Citudil-V
Is work related to a LAND-USE DECISION? WYes ❑ No Application reviewed:
If so,please specilFy(MLP,SDR,SUB,etc.) case#: By: Date:
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ les VNo By: Date:
If so,please specil)y(BUILDING PERMIT)case#: IACURPLN\Maslen\Land Use Apphudons nev o7/rcnol.
City of Tigard • 13123 SW Hall Blvd. • Tigard,Oregon 97223 • wwwugard-or.gov • 503-718-2421 • Page 1 of 4
APPLICANTS
NOTE: Person specified as".Applicant"shall be designated"Permittee"and shall prmide financial assurance for
work,if required by the cit}-pursuant to the.TNIC 15.011.140.
M\15th die exception of a utility operating pursuant to a rand franchise%vitt the City of Tigard,when the owner and the applicant are
diffe eut people,the applicant must be the purdnascr 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 authmization 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 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 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.
Applicant/Au 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 name Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.*rd-or.gov 503-718-2421 Page 2 of 4
DEVELOPMENT ENGINEERING FEES
1. Public Facility Improvement(PFI)Permit:
Part 1: Required subrnirtal tee 5100 00
Part 2: All uon-water system improvements
Engineer's estimate X 50,10(less$300.00 submittal fee)
Engineer's estimate X 2%Plan Review
Part 3: All public water system improvements
Engineer's estivate X 12%
Total Permit Fee=Part 2+ Part 3
PFI Permit Fee Exemptions:
There will be no permit fee charged,or assurance required for the following types of work
• Sidewalk or driveway repair(less than 20 lineal feet)
• Relocate or replace mailbox
• Ditch cleanung that docs not involve regrading.
• Weep hole repair
• Curb repair or replacement(less than 20 lineal feet)
• Lawn sprinkler system installation or repair
• Street tree pruning or planting
• Planter strip landscape maintenance
• Test wells
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • w«-Nutigard-or.gov 503-718-2421 Page 3 of 4
SAMPLE SKETCH:
Edge of Pavement
1 "40 Ditch
Streetlight -------------- —�---
1 f• a t�
"-rropoe €'r Me'
+ 1 Nit Existing Nouse
ai 1 Existing 1
.kr • Driveway
L 1 �1
CL' 1 vt r
Al
a,,,� i
-E
oI Existing Shop �
i
Powerpole ! I I 1
1. O •o
moi► �a 95' I
1 ------- -------
• 1 � -property Line
i1 Fire Hydrant(FH)
I 1 1
1 Scale: 1"=30'
1 f
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 parement Existing utility locations
D/W apron (sewer,water,storm)
.t..`:i!P.!-u[1.:?'�w'iFti u. ^ET5'A.^J•.�v'::ST'fi.T�....3w:.:.'"C.."MS:...: .' ie::sa"c�irr "_,Z 31.+F��•'32�3i u..^# :.iGv'n'YTh2':1:;.:f'P-.L"il9ilG.' '�`... ?L:'.C'�;ILS':':w••il^ �;S3Cd'A
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard - 13125 SW Hall Blvd. - Tigard,Oregon 97223 - Nvnvwtigard-ot.gov - 503-718-2421 - Page 4 of 4
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
2011 Edition Page 85
Stationary Lane Closure with Flagging Diagram 320
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SUBDIVISION LEGEND
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PIR.97R! 12/ � 54 !I HB 57 y' G� ` 1 CONSTRUCTION REQUIREMENTS
1 PO 33 40 _ I;B2. ".3. PGE STREET LIGHTS PROJECT MANAGER
SW ASHFORD ST JEFF STEIGLEDER 503-672-5462
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t\ IDRAWING
COw FIERIIK FACT IRS IN THE FIELD.THIS AW'ILLUSTRATES ELECTRICAL
FIWLL CJAOE W/EN II `r1DD L CONNEfTNRY,TYPES AND NUMBERS CIF CONDLICTORS AFD PLACEMEN Of ,qS-BUILT VERIFICA710N 8 NES[CONSTRUCTION VIOLA710N5 CORRECTED
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a S�Rdi n3iRMJ s"LigNG �'"f 6DR General Faaman: DNe:
' IREFEe.Fn LYSr.TIx.[c - •RDE I-' RIGHT-OF-WAY PERMIT NOTICE: (Sq^^H^• fo,field cansh—*-da
J� Pe MARY b SECONDARY SDPM-ENG REVIEW: ASBUILT BY DESIGNER:
A IERMR FROM THE IOC JURISDICTION 6 REQUIRED BEFORE ANv
J 0� 01/CTS(qM ENDS) f ED Y1T FT 1 WOIIK IN ME NIGHT -WAY MAY BE PERFORMED. ONLY WE AIPRCVEL ate-7�M SC'Nf 1':60' ACCO'PFr KI1000I A- 100000,0596 MM 77859
4 / SET O O �AL�T CONTRACTORS AND CONTRA BE A w HAVE MADE OTHER ME'Su
"R\ 0 0 .ego AGREFMEMS WITH WF WILL BE NlOWEO TO WORN UNDER WF'S PfRM11
�- [� 1 !61 THE CONTRACTOR MUST NOTIFY ME LOCAL JURISDICTION/B HOURS ` WNL PROPERTIES/HERITAGE CROSSING SIMOIVISION
n 4, 0 - Y'CO-DUCT - ' sr CONTACTISERVICE�COORD'NATOR -TORT wORx G To BEGIN.A COZY OF Mf PERMIT MUST r ON SITE. / DURH� _SA77�R ���
I �^- (IRIMMY-RNID SIDE ONLYJ
M \ J EaIRn Enraxr ro r w v-�”' r.,Nrr.No coHOPP..YNrm•r nroe CALL 111 RffORE YOU DIG �7 LDGTIw
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Y 6-DEEP(M" YANEF OAFS ARE SET FORM IN OAR-52-04)1) 1) INSTALL LPH 120240V LOG SERNCE TO NEW d]LOT SUBDIVISION
4• ALL SECONDARY PEDESTALS(M-300)TO BE INSTALLED ON PROPER-)ONES WITHIN ME&TIIfTY THI 152-00000)0.YOU AMY OBTAIN COPIES OF
EASEMENT AND AT FINAL GRADE.ALTERNATE LOCATIONS MUST RE A°PROVFD By PGf AND WILL CONFrr )
s• RI.lES h CML►K•INE mmus I!`NLIIY WASH CO 071-170
b
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