PFI2017-00102 VC 19
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 7//0//
Request for Permit Action
13125 SW Hall BIN-d. • 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 (✓):
CANC ' ID 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 #: PFI2017-00102
Site Address or Parcel #: SEG2468
Project Name: PGE
Subdivision Name: N/A Lot #: N/A
EXPLANATION: Per Engineering, permit is not required for this work because it's already
covered under PFI2016-00200.
Date: 6/7/17
Signature: ---ti�
Print Name: Lina Smith
Refund Policy
1. The city's Community Development Director,Building Official or City 1?ngineer 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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: ate By Route to Records: Date B
Refund Processed: Date B Invoice Processed: Date B
Permit Canceled: 1 Date / B Parcel Tag Added: Date B
I:\Building\Forms\RegPernvtAction_( 2314.doc
RECEIVED
City of
Tigard JUN 0 6 2017
g �
a PUBLIC WORhS -- ENGINEERINGLCITY OF TIGARC�
t p 17 PLANNING/ENGINEERING
7
Pubhc Facihtylmprovement (PFI) Perrmt
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
(� TYPE 1—Franchise Utility Work
Check one: X Utilities ❑Sidewalk/driveway approach ❑Streetimprovements performed by NWN, PGL
Detailed description: M2298869 Provide UG Service to New and/or utility-agency.
❑ TYPE 2—Sidewalk/Driveway/Sewer
Commercial Warehouse
Work performed for the purpose of:
--- • Sidewalk installation or repair.
15065 SW 74th Ave Driveway approach installation
Property address/location(s): and/or repair
SSG, �O • Sanitary-set;-er lateral installation
and/or main line tap
Applicant: Portland General Electric ❑ TYPE 3—Full scale Development
PP \Mork performed with Land use
Address- 10800 SW Avery St approval which includes any of
City/state: Tualatin, OR Zip: 97062 the following:
503-672-5481 rere coord n.com Subdivisions or Partitions
Phone: Email: P q @p9
Contact name: Chris Jewett Phone: 503-672-5481 Street-,6deniiZg
• Mainline installation for Sanitary
Contractor: 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 work in riglit-of-way"
Engineer: only may be enuuied to:
rowpermits jtigard-or.gov
Address:
City/state: Zip:
Phone: Email: Case No.: Cn
�I u n f ow o i
Contact name: Application submittal fee: $
Additional fees: $
Estimated value of work is required(if oi-er$5,000):$ Application accepted:
(within the public right-of-way) By: NL Date:
Is work related to a LAND-USE DECISION? El 1-es ElNo .application reviewed:
By: Date:
If so,please specify- (A1LP,SDR,SUB,etc.) case#:
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ les ❑ No By: Date:
If so,please specify(BUILDING PEFA1I 1)case#: l:\ENG\PennitApplications\pfi—application Rev.12/16/2016
Cityof Tigard • 13125 Sit'HallBh�d. • Tigard,Oregon 9 7223 • www tigard-or.gov • 503-715-2421 • 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 TNTC 15.041.140.
V"ith the c\certicm of a utility operatim,pursuant to a valid franchise with the Ciry of Tigard,when the owner and the applicant are different
pa I-AC.the aPplic.fflt must he the purchaser of record or a lessee in possession with Written authorization from the owner or an agcut of the
owiuer. The owttcr(s)must signs this application in the space provided or submit a written authorization with this application. Franchised
Utilities arc not required to obtain the owner's signature ort the applications
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
ro er -.
• 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 die
requirements for approving or denying the application.
\Jca Yd 2-c-2 k--7
Applicant/Authorized 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 • «>xxr,vtigard-or.gov, 503-718-2421 • Page 2 of 4
DEVELOPMENT ENGINEERING FEES
FOR STAFF USE ONLY
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
�7�
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 Rcview Sketch
(including information below)
WATER SYSTEM FEE
❑ Dimensions
Part 3: All public water system improvements ❑ Street Name
Engineer's estimate X 12% ❑ Sire 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. (G sets,?4:36 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 requiredper Storm,Sanitary,�X'ater,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 • «-vv-wtigard-or.gov 503-118-2421 Wage 3 of 4
SAMPLE SKETCH:
1 Edge of P avemerit
-- I
Ditch
Streetlight I ._... .,_._.—._._.,...�.._.-
1Ron t%14&L
1r 141
' T -VI op0Scf' 4w;I r,1-1r 1
1 rM 1
I c1� I a 1
1 NI d Existing House
I 1 Existing 1
! i >1 Driveway
�I 51
o
(L
O
ON
1 I M
W' I 1 ffi 1
W
W
� 1 1
o
Existing Shop
Powerpole 1 d 1
-7ropeWLni e- —
1 I Fire Hydrant(FH)
1
1 I
I1 ! Scale: 'I =30'
I I I
I
� 1 I
I 1
1 I
MINIMUM SKETCH REQUIREMENTS(Put"N/A"if Not Applicable):
North arrow Property lines & diunension 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 Std'Hall Blvd. • Tigard,Oregon 97223 • tvvm:tigard-or.gov • 503-718-2421 Page 4 of 4