PFI2018-00023 City of Tigard • comMUNITY DEVELOPMENT DEPARTMENTV
Request Permit Action
• 13125 SW Hall Blvd. • Tigard. Oregon 97223 • 503.718.2439 • www.ti arg_ dor.gov
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE T O: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓):
CANC OID 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 #: 1?F t 000 2-3
Site Address or Parcel#:
Project Name:
Subdivision Name: Lot#:
EXPLANATION: Lu'D I t CaLie of PT �2no( — ICJ
Signature: Datc: 2 5LB
Print Name:
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80"o of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
C) not more than 80"o of the land use application fee for issued permits.
d) not more than 80"o of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 800o of the building permit fee for issued permits prior to anv inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2-4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date By Rte to Bldg Admin: Date /� B
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date ,�- /� By Parcel Tag Added. Date By
Receipt# Date 'lethod Amount$
l:\Building\Forms\RcgPcrmitAction.doc Rei-05/25/2012
RECEIVED
FEB 0 5 2 018
City of Tigard CITY
Gi=T!GARD
PLAN
N
PUBLIC WORKS —ENGINEERING G/Ef! -GINEERING
Public FadhtyImprovement PFI Permit
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
TYPE 1—Francluse Utility Work
Check one: [_�Utilities ❑Sidewalk/driveway approach ❑ Streetimprovements performed by NWN, 13GE.
Detailed description: PGE Job M2205135 and/or utility agency.
Replace Bad Order Pole ❑ TYPE 2—Sidewalk/Driveway/Sewer
Work performed for the purpose of:
• Sidewalk installation or repair.
- Driveway approach installation
10105 SW McDonald Street
Property address/location(s): and/or repair
51�5r'l l(p42 Tigard, OR 97224 • Sanitary sewer lateral installation
and/or main line tap
Applicant: Portland General Electric[Submitted by Amy Sweany] ❑ TYPE 3—Full scale Development
pp Work performed with Land use
Address: 10800 SW Avery Street approval which includes any of
City/state: Tualatin, OR Zip: 97062 the following:
Phone: 503-844-5412 Email: preregcoord@pgn.com • Subdivisions or Partitions
• Street widening
Contact naive: SDPM Brandon Hadley Phone: 503-844-5412
• Mainline installation for Salutary
sewer, Storm sewer,Tigard water
Contractor: Portland General Electric Company
and/or Tigard Water Service Area
CCB#: 103663 Expiration: 12/21/2018
Address: SUBMIT COMPLETED APPLICATION TO:
City/state: Zip: City of Tigard
Planning/Engineering
Phone: Email: 13125 SW Hall Blvd.
Contact name: Phone: Tigard,OR 97223
Applications for"t11inor work in right-of-way"
Engineer:
only may be emailed to:
A roLvVermitr,@jjga'u� rd-or.goy
Address: FOR STAFFUSE
ONLY
City/state: Zip:
Phone: Etnail: Case No.:
Contact name: Application submittal fee(.007%of
Engineer's Estimate) $ 3Qo•�a
Estimated value of work is required(if over$5,000):$ NIA Additional fees:$
(within the public right-of-way) Application accepted:
By: AL_ Date:1
Is work related to a LAND-USE DECISION? ❑ Yes [!(No
If so,please specify (MLP,SDR,SUB,ctc.) case#: Application reviewed: Y
By: t 4-Date: IN
Is work related to a BUILDING PERMIT? ❑ Yes No Applicant notified:
If so,please specify(BUILDING PERMIT)case#: By: Date: 2 S
I:\ENG\PermitApplications\pfi—application Rev.10/16/2017
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CityofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • -,vwxvtigard-or.gov • 503-718-2421 Page l of4
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 tMvs application in the space provided or submit a written authorization with this application. Fruichised
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 unposed upon the subject
Drop
• 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 plait,attaclunents,and exhibits transmitted herewith,are true;and
the applicants so acknowledge that any perinit 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/Authorized Agent's signature Print name D6
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 ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • uxvwtigard-or.gov 503-718-2421 Page 2 of4
wL 1 PL 357x: OVERHEAD LEGEND
Install: REMOVE/ABANDON FACILITIES=INSTALL FACILITIES
PL 45'-3 INSTALL ADDITIONAL FACILITIESIMODIFY FACILITIES
1'WEST 7 WORKLOCATIONS
VD=2.19% D1 -------- SURVEY GRID BOUNDARY
1 P 7.2 120/240 OH 25KVA NT1 CS POLES
-- -- --�---- 3ACCOUNTS
j 19.57KVA HT-CL
POLE CLASS(1,2,3,4,H1,H2,S)
13995 a Q 1°.ios___`_____ 1ooa5 Transfer:
o N i3990 STREETLIGHT
POLE HEIGHT
U j Remove: FRAMING TRANSMISSION&DISTRIBUTION(SEE CODES BELOW,
- C2 1_oZC' PD1 45'-3 D1 _FRAME DISTRIBUTION-LC10710,MU 0001
y
---- ---- --- (1PHTANG,PIN)
___........... - 1P 7.2 120/240 OH 25KVANTICB
TEMP TRANSFER COMM(S),
PGE PULLED
TOPPED TO COMM(S)
3579 3578 TELCO TO PULL PGE OWNED POLE
45'-4 45'-3
-1996 10 35820 ------ --162'- --^ —- Ohe. --- - ----_C_.15.20 4 1408
_ e T 43 40`T' 240'-- - -------- --------
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as7 Open
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THINK PGE CONSTRUCTION DRAWING
SAFETY C�Y� AS-BUILT VERIFICATION 8 NESC VIOLATIONS CORRECTED
a7AF 1 rn: FIELD C-,,,-,
,
FIRST Foreman: Date:
General Foreman: Date:
(Signeture only required for field wnstrudion charges.)
SDPM/ENG REVIEW. SBUILT BY DESIGNER:
NYDEVL47TON FROM TMS DESIGN MUST 11is/2o17 ACCo
1 in=40 ft 1070001 0
6
00017443 M22b5135
BE APPROVED BY THE PGE PROJECT MANAGER TITLE
2016 OH FITNES-REPLACE B/O POLE
CALL 811 BEFORE YOU DIGCIRCUIT SIZE
ArrENTION: TIGARD-13337 11 x 17
OREGON LAW REQUIRES YOU TO FOLLOW RULES ADOPTED �, it /1/G
LOCATION
BY THE OREGON UTILITY NOTIFICATION CENTER. - � 10105 SW MCDONALD ST,TIGARD,97224
THOSE ROLES ARE SET FORTH IN OAR 952-001-0010 ^1.�E t r;. a DESCRIPTION
THROUGH 952-00I-0090 YOU MAY OBTAIN COPIES OF REPLACE B/O POLE 8 XFMR SHEET
THE RULES 0Y CALLING THE OREGON UTILITY COUNTYSECTIONS WDRK WITH
NOTIFICATION CENTER ADMINISTRATION @(507-232-1987) WASHINGTON 02111 B,C2102C 1 OF 1
TO REQUEST UTILITY LOCATES CALL THE OREGON whaftbekwwnsoRvace DESIGNBY PHDNEDRAWNBY
UTILITY NOTIFICATION CENTER,811 AT LEAST Calibefaeyou dig. LMC"WCERTFR BRANDON HADLEY 503-75&6436 CHRISTIAN CANON
2 BUSINESS DAYS PRIOR TO EXCAVATION WWSWBOECKAMANRn ®PORTLAND GENERAL r=L CTRIC CO.-AL RIGHTS RESERVED
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
------------------------
CD CA'D I 1 '"
n Ui CJS A A W W N N'aC O
CD U�O CT O C7 O CJl O W A I
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I for Low Volumes (Optional) o' Q
(n (ADT<4W) m
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m I s e c PREPARED O ROAD NE E `C
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3
— — . . .r. .— — — I ROAD
I ♦ PIN ® I WORK
o cWi) o C) ' I K c K 6 K s K A I---I I AHEAD
O O O N N I � ` I O
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0 0 0 o cn o " I ,ovranr, I A BTt
------------------------ =r
L 1 mile PRO _I 'T1
r max.
13
Buffer
Protection Vehicle
w/TMA(both Optional)
ROAD See Chapter 4
WORK �
AHEAD BE t3
ONE LANE 19
PREPARE w
ROAD AD TO STOP Two Flagger Operation
w CD
CD
(Optional) p Ln