PFI2018-00004 City Of Tigard 9 COMMUNI'T'Y DEVELOPMENT DEPARTMENT 1 1 1 0
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Request for Permit Action
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • «vvw.tigard-ongov
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 Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓):
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#: WI ?— d DWq
Site Address or Parcel #:
Project Name:
Subdivision Name: Lot#:
EXPLANATION: l�a-{� Q�
Signature: J&Adyl Date: I, is
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date By Route to Records: Date ; B
Refund Processed: Date /(/ B Invoice Processed: Date B
Permit Canceled: Date B Parcel Tag Added: Date B
I:\Building\Forms\RegPermitAction_ 9231 .doc
RECEIVED
City of Tigard JAN 0 4 2018 V,
CITY OF 11GARD I
PUBLIC WORKS —ENGINEERING � iNEERINr�
Public FacihtY Improvement (PF ermtt
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
TYPE 1—Franchise Utility Work
Check one: 174tilities ❑Sidewalk/driveway approach ❑Streetimprovements performed by NWN, 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.
Property address/locations : 13006 SW ROCKINGHAM DR - Driveway approach installation
and/or repair
��J_Wc A:?, TI and OR 97223 • Sanitary sewer lateral installation
and/or main line tap
Applicant: Portland General Electric[Submitted by Amy Sweany] ❑ TYPE 3—Full scale Development
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: preregcoord pgn.com - Subdivisions or Partitions
SDPM Chris Jewett 503-672-5481 • Street widening
Contact name: Phone:
• Mainline installation for Sanitary
Contractor: Portland General Electric(see above)
sewer, Storm sewer, Tigard water
and/or Tigard Water Service Area
CCB#: Expiration:
Address: SUBMIT COMPLETED APPLICATION TO:
City/state: Zip: City of Tigard
Planning/Engineering
Phone: Email: 13125 SW Hall Bbd.
Contact name: Phone: Tigard,OR 97223
Applications for"minor work in rif,4lt-of-way"
Engineer: N/A only may be emailed to:
roes Vermits(&ttigard-or,goy
Address:
City/state: Zip: •
it s,rAFF USE ONLY
PB�2(Phone: Email: Case No.:
Contact name: Application submittal fee: 300'
Additional fees: $
Estimated value of work is required(if over$5,000):$ N/A Applicati accepted:
(within the public right-of-way) By: z i D
ate:
Is work related to a LAND-USE DECISION? [IYes IY(No Application reviewed:
By: •�s Date:
If so,please specify (MLP,SDR,SUB,etc.) case#:
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes EX No By: 6L Date: el
If so,please specify(BUILDING PERMIT)case#: I:\ENG\PerrnitAppiications\pR_applicalion Rev.12/16/2016
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Ci off__Tigard 13125 SW Hall Blvd. Tigard,Oregon 97223 • wwwtigard-or.gov 503-718-2421 • Page 1 of 4
APPLICANTS
NOTE: Person specified as"Applicant"shall be designated"Perinittee"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 frmichise with the City of Tigard,when the owner and the applicmit are different
people,the applicant inust be the purchaser of record or a lessee iii 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 silniattue on the application
BY SIGNING BELOW,THE APPLICANTS) SHALL CERTIFY THAT:
• The above request does not violate any recorded deed restrictions that tray be attached to or imposed upon the subject
property.
• 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.
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
M 39
REPLACE B/O CABLE
2F.4 DRIVEWAY CUT REQUIRED
B 25 64 23 20•- 1997
1997
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I �
G ATTENTION: CALL 811 BEFORE YOU DIG
3110 OREGON LAW REQUIRES YOU TO FOLLOW RULES ADOPTED '
m BY THE OREGON UTILITY NOTIFICATION CENTER. ,
1 THOSE RULES ARE SET FORTH IN OAR 952-001-0010
} THROUGH 952-001-0090.YOU MAY OBTAIN COPIES OF
THE RULES BY CALLING THE OREGON UTILITY
B 50 62584 NOTIFICATION CENTER ADMINISTRATION Q (503-232-1987)
-- TO REQUEST UTILITY LOCATES CALL THE OREGON Know what's below.
UTILITY NOTIFICATION CENTER,811 AT LEAST Call before oudi
?BUSINESS DAYS PRIOR TO EXCAVATION. Y 9•
PGE CONSTRUCTION DRAWING
SDPMfNG REVIEW: JASBUILT BY DESIGNER:
AS-BUILT VERIFICATION & NESC VIOLATIONS CORRECTED
This document accurrfPly rPnresentc FIELD ronorurtion.
Foreman: Date:
GF: Date:
DATE: 12118/2017 SCALE: WA ACCOUNT: 5940001 AWO ..4000000658 JOB NO.M2449115
TITLE JEREMY M WEIDMAN
CIRCUIT TIGARD-13362 SIZE
PGE i 1x17
LOCATION 13006 SW ROCKINGHAM DR., TIGARD
THINK ` DESCRIPTION REPLACE BIO CA BL E
SAFETY COUNTY ECTION(S) WORK WITH SHEET
BEAVERTON WASHINGTON C2104D
1 OFT
FIRST! LINE CREW CENTER DESIGN BY PHONE(503) DRAWN BY
2213 SW 153RD ORCHRIS JEWETT 672-5481 CHRIS JEWETT
BEAVERTON,OR 97006 Q PORTLAND GENERAL ELECTRIC CO.-ALL RIGHTS RESERVED
—————————————
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1
Agnes Lindor
From: Prereq Coord <PreregCoord@pgn.com>
Sent: Wednesday, January 10, 2018 8:25 AM
To: Agnes Lindor
Subject: RE: NEW City of Tigard Permit Application, 13006 SW ROCKINGHAM DR, PGE Job
M2449115
Yes please. Thanks so much, Agnes.
Lien Saddler
PG£pre4-equ4v;izi Cocrd,:.na v m
(503) 612-6103
Cell., (9 71) 3 71-0201
/PGE/
From: Agnes Lindor [mailto:agnesl@tigard-or.gov]
Sent: Wednesday, January 10, 2018 8:24 AM
To: Prereq Coord
Subject: RE: NEW City of Tigard Permit Application, 13006 SW ROCKINGHAM DR, PGE Job M2449115
***Please take care when opening links, attachments or responding to this email as it originated
outside of PGE.***
Hi Linda-
am not in the office today, but I will look at it tomorrow. I think it may have been submitted twice. If this is the case,
would you like me to cancel the 2018 one?Thanks,
Agnes
From: Prereq Coord [mailto:PreregCoord@pgn.com]
Sent: Wednesday,January 10, 2018 8:21 AM
To: Agnes Lindor<agnesl@tigard-or.gov>
Subject: RE: NEW City of Tigard Permit Application, 13006 SW ROCKINGHAM DR, PGE Job M2449115
Hi Agnes. We have PF12017-00281 for this work (and paid for). Just wondering if this one needing payment (PF12018-
00004) replaces it or does it need to be cancelled?
LL4 , Saddler
PGE Pre-ecju Covxrd ivtat'wty
(503) 612-6103
CeW.- (97x) 3 71-0201
PG E/
From: Agnes Lindor [mailto:agnesl@tigard-or.gov]
Sent: Tuesday, January 09, 2018 3:04 PM
To: Prereq Coord; ROW Permits
1
Cc: Melissa Griffith
Subject: RE: NEW City of Tigard Permit Application, 13006 SW ROCKINGHAM DR, PGE Job M2449115
***Please take care when opening links, attachments or responding to this email as it originated
outside of PGE.***
Dear Matt,
Your permit is ready for $300.00 fee payment. You can pay the fee online by clicking this link:
htti2s://aca.accela.com/tigard/, go to the "Engineering" tab, search for record number PFI2018-00004.
Then, go to the "Payments" tab and click "Fees" to submit your online payment. Please notif, us once
you've paid, and we can release the permit.
Thank vou,
Agnes Lindor Associate Planner
City of Tigard Community Development
13125 SW Hall Boulevard
Tigard, Oregon 97223
Phone: 503.718.2429
Email: AgnesL@tigard-or.gov
From: Prereq Coord [mailto:PreregCoord@pgn.com]
Sent:Thursday,January 04, 2018 12:03 PM
To: ROW Permits<rowpermits@tigard-or.gov>
Cc: Melissa Griffith<Melissa.Griffith@pgn.com>
Subject: FW: NEW City of Tigard Permit Application, 13006 SW ROCKINGHAM DR, PGE Job M2449115
Importance: High
Hi. We have this work scheduled for tomorrow (1/5/18). Is it possible to get this permitted today?
L Lvi.da.S aJz l er-
PGF Prerequ4ae Cao-rd+-iaUo-n/
(503) 612-6103
Ce& (9 71) 3 71-0201
PGE.y
may.
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.
2
Amy Sweany
Administrative Assistant
Portland General Electric
10800 SW Avery St.,Tualatin, OR 97062
503-612-2935 1 Amy.DeeSweany@pgn.com
DISCLAIMER: E-mails sent or received by City of Tigard employees are subject to public record laws. If requested, e-mail
may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law. E-mails are retained
by the City of Tigard in compliance with the Oregon Administrative Rules "City General Records Retention Schedule."
3