PFI2017-00128 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
N
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: 503-598-1900 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 ITEM(S) CHECKED (✓):
M 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 #: Pf l2( I—00(2-1�
Site Address or Parcel#: �`}(0
Project Name:
Subdivision Name: Lot#:
EXPLANATION: RIS klS AIM44 rfAlfwd U&ift Mmrt
Signature: Date:
Print Name: Aenncs L'I h"J(S`Ye,
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 By Route to Records: Date, / /2 B
Refund Processed: Date Al rl By Invoice Processed: Date B
Permit Canceled: Date % �y I By Parcel Tag Added: Date B
I:\Building\Forms\RegPermitAction_ 92314.doc
RECEIVEDCity o f Tigard �y
■ �, � � 2017
PUBLIC WORKS — ENGINEERING JULJ�� 9
Public Faces Improvement P
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
❑ TYPE 1–Franchise Utility Work
Check one: 0 Utilities ❑Sidewalk/driveway approach ❑Street improvements performed by NWN, PGE
Detailed description: Install short side svc; main is on the 6'in ROW under and/or utility agency.
earth//WR#3504011 ❑ TYPE 2–Sidewalk/Driveway/Sewer
Work performed for the purpose of:
• Sidewalk installation or repair.
15065 SW 74th Ave#New • Driveway approach installation
Property address/location(s): /� n / and/or repair
'JEL1 4=0 i.(� • Sanitary sewer lateral installation
and/or main line tap
Applicant: NW Natural El TYPE 3–Full scale Development
pp Work performed with Land use
Address: 220 NW 2nd Ave approval which includes any of
City/state: Portland, OR Zip: 97209 the following
Phone: 503-226-4211 x4428 Email: nwnpermits@nwnatural.com • Subdivisions or Partitions
Contact name: Aisha Rivers Phone: • Street widening
• Mainline installation for Sanitary
Contractor: Loy Clark sewer, Storm sewer, Tigard water
and/or Tigard Water Service Area
CCB#: 52281 Expiration:
Address: PO Box 1369 SUBMIT COMPLETED APPLICATION TO:
City/state: Tualatin, OR Zip: 97062 City of Tigard
Phone: 503-849-3295 Email: jim.fitzgibbon@loyclark.com Planning/Engineering
13125 SW Hall Blvd.
Contact name: Jim Fitzgibbon Phone: Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: NW Natural only may be emailed to:
Address:
220 NW 2nd Ave ro :permits(itigard-or.gov
, 97209
City/state: PortlandOR Zip:
FOR s'rAFF USE ONLY
Phone: 360-921-0314 Email: r2g@nwnatural.com CaseNo.:T�f�� ML�*
Contact name: Application submittal fee: $
Additional fees: $
Estimated value of work is required(if over$5,000):$ Application accepted:
(within the public right-of-way) By: L%C -Date: 5h
Is work related to a LAND-USE DECISION? ❑ Yes ❑ 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#: l:\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 owner(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 any recorded deed restrictions that may be attached to or imposed upon the subject
prope
• 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.
Digitally signed by Aisha Rlvens
Aisha Rivers DNNatural,
cn=A£he Rivers,o=NW =Enal.=n,g Aisha Rivers 7/19/17
Technical Coordinator,emell=aap@ou
nwnatural.com,
c=US
Date:2017.07.19 13:27:20-07'00'
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 • www.tigard-or.gov 503-718-2421 • Page 2 o,f 4
DEVELOPMENT ENGINEERING FEES FOR STAFF t'SE' ONLY
Public Facility Improvement(PFI) Permit:
DETAILED
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: 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 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 • www.tigard-or.gov 503-718-2421 0 Page 3 of 4
SAMPLE SKETCH:
Edge of Pavement
I — Ditch ----
StreetlightRain Dvoin
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T'rropos' cf"Selwer'rRF��
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Fire Hydrant(FH)
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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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2011 Edition Page 95
Self-Regulating Lane Closure Diagram 350
ROAD *t I I to
WORK B
Initial AHEAD •
Warning •
Sign •
A •
•
ONE LANE i•
ROAD I
AHEAD
Protection vehicle • TO YIELD
w/TMA(both Optional) ONCOMING OR TO
See Chapter 4 • TRAFFIC ONCOMING
TRAFFIC
• IlBuffer
•• 50'-100'
T15'
�OR+1(
A
ONE LANE
B ROAD
AHEAD
ROAD
C WORK
Initial
AHEAD
Warning
Sign
December 2011 Chapter 5
Page 94 2011 Edition
,
Self-Regulating Lane Closure Diagram 350
Use this detail for closures of one lane of a low-speed, two-lane, two-way
road.
1. Use this diagram only if all of the following are true:
a. Work space is less than 200 feet.
b. The posted speed is 40 mph or less (unless not posted and
speed governed by basic rule).
c. Average Daily Traffic(ADT) is less than 400.
d. Sight distance (in feet) is more than 750 at each end.
2. Use truck-mounted flashing warning lights on work and protection
vehicles. See Section 4.3— Lights and Lighted Signs for exceptions.
3. For added visibility, a truck-mounted arrow panel or PCMS in caution
mode may be used.
4. A"Lane Ends (Right)" (W4-2R)symbol sign, or"RIGHT LANE ENDS"
(W9-1 R) sign, may be placed inside the cone taper for more emphasis.
Sign Spacing and Buffer Lengths(feet)
Posted Spacin Between Signs Buffer
Speed A B C Space
20 50
25 100 100 100 75
30 100
35 40 350 350 350 125
150
45 180
50 500 500 500 1 210
55 250
Chapter 5 December 2011