PFI2017-00282 City of Tigard • COMMUNII"Y DI~;VBI.OPMENT DI:PtkR"I'MI:NT
14
Re uest for Permit Action
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13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.g_ov
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 Indwidual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
_...__
CANCEL OID PERMIT APPLICATION.
D 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#: ?F1 200 002Y OZ
Site Address or Parcel#: 05
Project Name:
Subdivision Name: Lot#:
EXPLANATION:
r
Signature: Date: S
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FO11 OFIACE' LSE, ONLY
Route to Sys Admin: Date By Route to Records: Date o2 &oC4B
Refund Processed: Date/V/4 B Invoice Processed: Date B
Permit Canceled: Date B - Parcel Tag Added: Date 'RIT
I:\Building\Forms\Regl'ermitAction_)9231 .doe
Agnes Lindor
From: Prereq Coord <PreregCoord@pgn.com>
Sent: Friday, January 05, 2018 2:00 PM
To: ROW Permits
Cc: Prereq Coord
Subject: FW: NEW City of Tigard Permit Application, 13006 SW ROCKINGHAM DR, PGE Job
M2449115
Attachments: M2449115 City of Tigard Public Facility Improvement Permit Application SIGNED.pdf;
M2449115 Sketch.pdf; M244911S TCP.pdf
Good afternoon. Mike called and left me a voice mail message this week. However, I've been 000 sick and just now
returning.
I also have hearing aids in both ears. Unfortunately, Mike spoke so quickly I didn't catch his number.
I did, however, hear that two permits were issued for this project: PF2017-00281 d 2017-00282.
Please feel free to void either permit and send us the valid permit.
Thank you for everything that you do,
/ Amy Sweany
f PGE Administrative Assistant PSLD • 503-612-2935 . 503-612-6150f
� )
10800 SW Avery Street Tualatin, OR 97602
PortlandGeneral.com • Follow us on social @PortlandGeneral
From: Prereq Coord
Sent: Wednesday, December 27, 2017 4:20 PM
To: ROW Permits
Cc: Tami Mackay; Chris Anderson; Prereq Coord
Subject: NEW City of Tigard Permit Application, 13006 SW ROCKINGHAM DR, PGE Job M2449115
Good afternoon.
Attached is the City of Tigard Permit Application,Job Sketch, and TCP for PGE Job M2449115.
Please contact SDPM Chris Jewett at 503-672-5481 with any questions.
Thank you for all that you do.
Amy Sweany
Administrative Assistant
Portland General Electric
10800 SW Avery St., Tualatin, OR 97062
503-612-2935 1 Amy.DeeSweany@pgn.com
1
V r) DRECEIVED
City of Tigard ������ D E C 2 8 2 01
PUBLIC WORKS —ENGINEERING
CITY OF��IGARD
Public Facility Improvement (PFI)"'Ptrft� t AINEERING
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
TYPE 1—Franchise Utility Work
Check one: Utilities ❑Sidewalk/driveway approach ❑S tree t improvements performed by N%N, PGE
Detailed description:
OUT 327152 B/O HOTLEG INST MMC and/or utility agency.
SS 6 C2104D 365 TRANSF 64723-25KVA ❑ TYPE 2-Sidewalk/Driveway/Sewer
Work performed for the purpose of:
• Sidewalk installation or repair.
• Driveway approach installation
Property address/location(s): 13006 SW ROCKINGHAM DR and/or repair
Tigard, OR 97223 • Sanitary sewer lateral installation
and/or main lune tap
Applicant: Portland General Electric[Submitted by Amy Sweany] ❑ TYPE 3-Full scale Development
PP Work performed with Land use
Address: 10800 SW Avery St, approval which includes any of
City/state: Tualatin, OR Lip: 97062 the following:
Phone: 503-612-2935 Email:preregcoordapgn.com • Subdivisions or Partitions
Contact name: SDPM Chris Jewett Phone: 503-672-5481
• Street widening
• Mainline installation for Sanitary
Portland General Electric see above server, Storm sewer, Tigard water
Contractor: � )
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 Bbd.
Contact name: Phone: Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: N/A only may be emailed to:
rowpermits(a)tigard-or.gov
Address:
City/state: Zip:
Phone: Email: Case No.: FE[20l- UD2b Z
Contact name: Application submittal fee: $
Additional fees: $
Estimated value of work is required(if over$5,000):$ N/A Application accepted:
(within the public right-of-way) By: Date: 7i
Application reviewed:
Is work related to a LAND-USE DECISION? ❑ Yes E(No
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\PermitApplicatbns\pfl_appllcation 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 frvichise with the City of Tigard,when the owner and the applicant are different
people,the applicant must be the purchaser of record ora lessee hi 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 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 the
requirements for approving or denying the application.
Z Zv
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 • wwwtigard-or.gov 503-718-2421 • Page 2 of 4
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REPLACE B/O CABLE
25-4
DRIVEWAY CUT REQUIRED
B 25 64 23 20- 1997
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I1 C ATTENTION ,
1,31 10 OREGON LAW REQUIRES YOU TO FOLLOW RULES ADOPTED
BY THE OREGON UTILITY NOTIFICATION CENTER. ,
THOSE RULES ARE SET FORTH IN OAR 952-001-0010
THROUGH 952-001-0090.YOU MAY OBTAIN COPIES OF
THE RULES BY CALUNG THE OREGON UTILITY
NO
B 5U 62584
NOTIFICATION CENTER ADMINISTRATION @ (503-232-1987)
'O REQUEST UTILITY S CALL THE OREGON Knew wWs below.
UTILITY NOTIFICATION CENTER,811 AT LEAST Calld'
2 BUSINESS DAYS PRIOR TO EXCAVATION. 1 O•
PGE CONSTRUCTION DRAWING
SDPAMENG REVIEW: ASBUILT BY DESIGNER:
AS-BUILT VERIFICATION & NESC VIOLATIONS CORRECTED
This document accurately represents FIELD construction.
Foreman: Date:
GF: Date:
DATE: 12,11812017 SCALE: WA ACCOUNT: 5940001 AWO:3000000658 JOB NO.A42449115
N"."
MLE JEREMY M WEIDMAN
\\ CIRCUIT TIGARD-13362 SIZE
1 1x17
PGE LOCATION 13006 SW ROCKINGHAM DR., TIGARD
THINK ` DESCRIPTION REPLACE BIO CABLE
SAFETY COUNTY ECTION(S) WOR7 SHEET
BEAVERTON WASHINGTON C2104D 1 OF I
FIRST! UNE CREW CENTER DESIGN BY PHONE(503) DRAWN BY
2213 SW 153RD DR CHRIS JEWETT 672-5481 1 CHRIS JEWETT
BEAVERTON,OR 97006 0 PORTLAND GENERAL ELECTRIC CO.-ALL RIGHTS RESERVED
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