PFI2017-00109 V 0
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action
13125 SVS' 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 I'igardBuddingPermits@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 ANION FOR THE ITEMS) CHECKED (✓):
_�ANCC
EL SID PERMIT APPLICATION.
ND 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#: 0:51-;2017-Ute%0'7
Site Address or Parcel #: / 35 C B 00 X10
Subdivision Name: Lot #:
EXPLANATION: Oerpe
Signature: Date: & Z21"
Print Name:
Refund Polity
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 farm of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONL)
Route to Sys Adn in: Date By Route to Records: Date /p / B
Refund Processed: Date IV ,4' B Invoice Processed: Date Bt-
Permit Canceled: Date / B Parcel Tag added: Date Bv
1:\Building\f-'orrns\RcgPcrmitAction_I 1 2314.doc
V RECEIVED
City f Tigard 7 JUN
PUBLIC WORKS — ENGINEERING ���T
Public FaciliPFI C GIm rovement Peri-r ��A °
I
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of--way)
❑ TYPE 1—Franchise Utility Work
Check one: ❑ Utilities ® Sidewalk/driveway approach ❑ Street improvements performed by NWN, PGE
Detailed description: 3 Pavement Cores in paved trail, 6-in. diameter. and/or utility agency.
3 Borings in paved trail and 3 Borings adjacent to trail, Borings P9 TYPE 2—Sidewalk/Driveway/Sewer
Work performed for the purpose of:
to 5 ft. max depth X 5-in. diameter • Sidewalk installation or repair.
• Driveway approach installation
Property address/location(s): Paved trail on north side of SW Tigard and/or repair
Street between Hwy 99W and SW Tiedeman Avenue • Sanitary sewer lateral installation
PAVU (&_ t 5 l 1z;5 C_BD o and/or main line tap
Applicant. Geotechnical Resources, Inc.(GRI) ❑ 'TYPE 3—Full scale Development
pp Work performed with Land use
Address: 9750 SW Nimbus Avenue approval which includes any of
City/state: Beaverton/OR Zip: 97008-7172 the following:
Phone: 503-641-3478 Email: gtupper@gri.com • Subdivisions or Partitions
Contact name: Gene Tupper Phone: 503-641-3478 Ex: 121 • Street widening
• Mainline installation for Sanitary
Contractor: Custom Hole Drilling, Inc. sewer, Storm sewer, Tigard water
and/or Tigard Water Service.Area
CCB#: 69461 Expiration: 8-4-18
Address: PO Box 384 SUBMIT COMPLETED APPLICATION To:
City/state: Molalla/OR Zip: 97038 City of Tigard
Phone: 503-829-3364 Ems: dale@customholedrilling.com Planning/Engineering
13125 SW Hall Blvd.
Contact name: Dale Chapman Phone: 503-829-3364 Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: Alta Planning +Design(Architect) only may be emailed to:
rowpermits Cgs tigard-or.gov
Address: 711 SE Grand Avenue
FOR STAFF I'SE ONLY
City/state: Portland,Or. Zip: 97214
Phone: 503-230-9862 Email: devenyoung@altaplanning.com Case No.: W12V«
Contact name: Deven Young Application submittal fee: $
Additional fees: $
Estimated value of work is required(if over$5,000):$ Application accepted:
(within the public right-of-way) By: ALDate:
Is work related to a LAND-USE DECISION? ElYes N No Application reviewed:
By: Date:
If so,please specify (MLP, SDR,SUB, etc.) case#:
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes ® No By: Date:
If so,please specify(BUILDING PERMIT)case#: I:\ENG\PermitApplications\pfi—application Rev.12/16/2016
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-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,if
required by the city pursuant to TMC 15.041.140.
* With the exception of a utility operating pursuant to a valid franchise with the City of Tigard,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 owncr(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 ani recorded deed restrictions that may be attached to or imposed upon the subject
12rol2em.
• 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.
M- Gene M.Tupper, PE, GE June 21,2017
Applicant/Authorized Agent's 2CAure 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
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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
Public Facility Improvement(PFI)Permit:
DETAILED
APPLICATION FEE
Part 1: Required submittal fee$300.00
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% ❑ Site 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. (6 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 be 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
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PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 3 of 4
SAMPLE SKETCH:
Edge of Pavement
I
I – Ditch
Streetlight I .—.—.— .—•—.—.—.'C—.—
}� reRain Drain
1 � r rir Trema
Tl I roposd�5ower'Ti'Ile
" �
I "� I Existing House 1
Existing
21 Driveway 1
�'01
I 1
IL I �
L: I I r l
01
13
I I '
E .
>' I 1
of
Existing Shop
C9 -
Powerpole
�- s 95
o ' I
'--------'l ------_---
I 0 p e rtp"L ni e'
I .
Fire Hydrant(FH)
I
I I I
Scale: 1"=30'
� � I
I I I
I I
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I I I
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/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
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