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PFI2018-00134 City of Tigard o COMMUNITY DEVELOPMENT DEPARTMENT S .3 , to Request for Permit Action 04 D 13125 SW Hall Blvd. ° Tigard, Oregon 97223 - 503-718-2439 - w-,v-,v.tigard-or.gov TO: CITY OF TIOARD 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 ITEM(S) 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 #: PF12018-00134 Site Address or Parcel #: SEG1026 Pro)ect Name: Frontier Communications Subdivision Name: N/A Lot #: N/A EXPLANATION: Applicant requests to cancel permit. Date: 6/5/2018 Signature: ----.- Print Name: Lina Smith Refund Policy 1. The city's Community Development Director,Building Official or City Fnfnneer may authorize the refund of: o Any fee which was erroneously paid or collected. a Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. o 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 S s.Admin: Date By Route to Records: Date ej1Zy tj— B Refund Processed: Date IV , B 7 Invoice Processed: Date By Permit Canceled: Date Bj; Parcel Ta Added: Date B L\Building\Forms\RcgPermitAction_ 9'2314.C1oc �r aFRI RECEIVED ...........01)5.5-1 - II/Z) � J U N 4 2018 city Of-rigard PLAMIC \101110 FING f 40 10111 MAa Public 1"1j(:jjjtjT 1 --()VCjj1 -I k;,33C Pet wn ,w r .> 1ATE OF WORK DJ-,;SGRI P11 0 N C 1 't=)Iti I (i.n the t-o1*-\A,,,ay) (.h(:ck omt I_. i.iliii,�� [--! 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'�A';li'; ��(�(?�3�;allc,n:,c (a IC^.c r - ,, - � _..__�.u•--ifs- 1.:i.,. _-- _�_—_. 1 S v t,Ck,r r I,II_c i to tl 1ILiI j,D I NG PI__1t I II.r (_.I `l,u ='til)plit.<,I)i I t ihic. I j r. .. g C�rt:���i/f :-t��r-� � i.>1?�,,�\\�' 1�i:l! (.�i°,`tY. I r" ;€t_i, ..�i �rtt . , _''."', w ,,���t a (,� rtcl��::�1�s !�t� 511-AS-2-121 APPLICANT'S N011-71: i"ApnhC;m.C',"diall I)c d "IP11;[tcd 'Tcl-miticc' mid p1-ovi(.1c ('(,)v\vl 11 h\ the citi, pur,�'Uftffl 1(.) '1 1 ()"[1 .j l-.-. ]it lki", il wS� Ci,l: I, ,vfl 11 it!,n T1 t"r t 1 1 I.,il v.ti....l3EI .1 Fit!, SI- AT,A-CERTIFY'I'VIXT: thc Ihovcrc,.glc�t dol nol "Iolat:c Hl i-CCO(�c1cd l rest'rictirtill, th:o 111o. hc;11A,ac.h,cd �,iour t "looll rhc,,�uhica .......... ................ .................. -------- I'l I c 'IpI 1 C"H'i()t I is r"I rd co 1, t 1)(,' �Ipp 11 c"I I I r Nvi 1*1 c�,'c rc tsc I I I : i-1,c I1 i ITC d 111 .1 cu3 rdal Ick""1,t I th c td,C1 I I �lll J u N ccI f-.) 1,_1 1-1)c IJ 111C it (a Thc A11,clllcilf-ti -md ph o,phil, mwillm"111.4,and cxhdlits acd hcrcw ill,iIrr 'Illd -1,111t -�ucd, on d I's q)p! (,1;11 on,MA,v be rcvokcd U[-it Is F(AM.d 11m.1 "Itiv-such t]I c;Ipphc,mt-,�"o ifiail 1)c I. I I T t r Thc :Ippl cmir 11'a.,-� rc�ld I-11C C111, I I rc I 11,c,I I I�,o f 1)1{.' 1 c( c ;IIIc c I I c 6 1 111 111 1-'s t:a j 1, 1.)c 1-c qI I I I cl I cn t s r;t rr)v i I I�1,i: 1:d cI 11 lu 11 1 1i:t17cS1, -I,I rc n;m1c P A, SIGNATUTES ofeach-mvner of 11be subject J:m C)v,'n(-,1 Ce nall 0 I.J ...W._.. ..... ....................... [c Im(ur(: PUBLICEACILLY11",t f'4 Clit.yofTigard 1-1125 �"1Vlh11 1>'1%,], il, # 2 2 11agc 7 o DEVELOPMENT ENGINEEIUNG FEES Public Facility Impro-vement(PFI) Permit: D D D 6A P W APPLICATION FEE Part l: Acquired suhnilmil fee$300,00 FRANCHISE UTILITY AND SIDEWALK/ PERMIT FEE DRIVEWAY AND UTILITY CONNECTIONS,ETC. Part 2: X111 nail-�t�atci:��-stem ir»provcmcll(s {word;it, the right or way)estirnittc X 5`'(,(loss`�1(1<J.tl�l snbnlimil Fee) f-npricer's esrinlat:e N 2`'io l'fan Movie«• Slretcb {includiirgir.rlorrnaliorr below) WATER SYSTEM FEE ❑ Dirncrlsrc)rIs Part 3: All public Wirer system inlprovemcilt's ❑ Strcet N:1Inc f;nincet's estimate 12"`�r El Site_Address PFI Permit Fee Exemptions: FULL SCALE DEVELOPMENT There will be no permit fcc cline-ged,or itssurtiwe required .incl Street Ill for the following types of work: (�EII)CIIVltilotl::/P:u tilian� Sldew;lllc repair'(ICSS H121120 lirlcid feet) ° Design Plansl:clocac or rephice m,ulbox (6 sets,24x36 or 22x.34) ° Duch rlt:anI g dlat dc)es not-i1lv0lvc I-Cgt�ldin�;. llolc 1:cpaii, ❑ Cover--Silc,Vicinity,Abbreviation,Legend ° C-Urb 1'C1lRI1-or'1'C:p111C,Ci11C11t(lc is thatl 20 1111Ca1 EcCt-) ❑ General Notes(City,Walcr,Sewer,etc.) Lawn Sprinkler s\;stem ittstilll"ttioll or repair. ❑ Strcet{l ki ,].'route) ° Street tree P11111ML�OV I)Ltnttilg ❑ W"ater,Storm and Sanitary(Plan Profile) ° PIart ter srrxl)lillldsc�ipe ill iliatel 1'lrlcc ❑ Water Quality t'aclllllcs • 'rest wells ❑ GI•ading (� L,rnclscal�ing/I'rec Plan ❑ Composite Utilise 11.In(L.'lectrical,Phone,Gszs, Storm,&1111t;try,Water.,signage,Street lights,etc) Note A cash assurauce Alla),be required per T41C 15.04.140. (C11Stolrlerdeposit) F1rtsiils T ❑ Traffic'sight Distance ❑ Signing And Striping ❑ Stxeet Lig lit Ilan and Photometric ❑ 'l Ingincers seal/sigiriturC ❑ Sheet label(pro)CCt.land use mento,recision,incl JAIII los;block,elates-Incl sheet:numbers.) Additional Subnditals {per L,arul i_tse conditions) ❑ Tnifllr Report ❑ Slorin water Drainage(;alculations ❑ Geotechnicall1'�eport ❑ 1'relirninary Access 1�cport(Sight Distance) ❑ 1'roposcd flat ❑ Pathway Design(if applicable) ❑ Water 1)cpxartrnent Approv:ll ❑ l?att,>iricer's Construction l siimnte PUBIAC FACILITY IMPROVEIIIENT PERMIT City of Tigard ° 1312.5 S\\,'[-hill Blvd. ° Tigrlyd,Oregon 97223 503-718-2421 ° Page 3 of 4 SANITIL 2-A 7- ssurcu: L Edge Wavement 3t r e e f I iij h t ---- —- —-— -— -—- —-7r—' �,�L'i, 1% :[, 4P RAI MY 0 771 i s, i ri H o e WAng C i nL f A ,h moi, _ °P -- Fire Hydrant(FH) ,M[NITNIIJINT SKETC14 (Put"N/.All if Not Applicable): VOIS Army, of; propci-I'v Sircel- LJIidity& p("'Ic's Sisriny",�,-Llrh ol- \V DAN, (Aly cjllgar(l �)\V I LRI [Avd. hpud(04ym 07223 w" 142421 Page 4 cf/ `77 �1, ..M 644A 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 vOILIme 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-1110unted arrow board or PCMS in caution mode nmy 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 closrlre. 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 Cl0Sure with Pilot Car"if exceeding one mile. 5. Cones should be Used to Outline the work space when curves or other roadway alignments preverrf:clear direction for the motorists to pass the work space safely. G. Cones along the work space are recommended when hosted speeds are 45 mph or greater, when working under heavy traffic or when travel lanes are narrower than 11 fr�ct. T Extended queue signing(see Diagram 5-4)shorlld 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 learning and Flagger Ahead symbol signs may be placed on the side road(s). 9. Sign set-Lip and flagger placement shown may be used for intermittent kill road closures of 20 minutes or less. 10. The"ONE LANE ROAD AHEAD" (W20-4) sign is optional and shOLIld be considered on high volume or high Speed roads, or when extended queues are expected. Chapter 5 DecorT ber 20-11 Single Flagger OperationFTI ioYxa r, f ` for Low Volumes �- � (Op,ional) Q w (ADT<4J0) n PAR�G� ONE LANE PREP � z c ROAD i o o TO STOP AHEAD r W --— a-- ROAD CD WORK AHEAD V A • Ara�x vnntie � � ,, a m 401 (� y F � I riffle — -- . ._.. .......... . .. max. y <21 F B AFT Buffer v 1 Protection Vehicle w/TMA(both Optional) ROAD See Chapter 4 C_7 'Y'VORK i AHEAD BE: Ro a E `Cwo Flagger Operation PREPARED W AyEAD TO STOP s (Optional) Q m ' 1 # 280 09.2006 YJD TGRDORXA H1004,97-135+ 195' XD,40--48 AKF 25 24 BBGTD 3,1801-1825 12437 SW HALL BLVD "DOR" OID#37964096 432 09.2006 0 APT 10 YJ D 48 co co TGRDORXA H1004,97-1 N 500 09.2006 FTTP PIGTAIL 50OFT 4 e Q �� TGRDORXA H1004,142-144+ XD,4 `o 3GO O N 0) O �Qa no 32065 C2102A1522 �o FRONTIER TGRDORXA 46570 "A+' TGRDORXA H1004,142-14 - - - m J 32067 C2102A1524 XD,4 n FRONTIER � SHEET Z OF 2 500 06.2018 fl�� 500211 C2102A5754 2© $ PORTLAND GENERAL ELECTRIC NORTH FTTP PIGTAIL 500FT 12 C.O. XD,1-3+ E TGRDORXA H1004,136-139+ � TGRDORXA 7S7 32066 XD,8-12 FRONTIER SW SCOFFINS ST 260458 C2102A4303 O 361202 PORTLAND GENERAL ELECTRIC TGRDORXA H1004,136-139+ 0 206.2018 1 - XD,8-12 12-FIBER 12 XD,1-3+ TGRDORXA H1004,136-139+ XD,8-12 comrnuni-ations TGRD/37964096-"DOR" 041-51351-5223739-43 12437 SW HALL BLVD PROJECT I C.O.AREA- 041-51351-W0644449 REA041-51351-W0644449 NUMBER: W 6444A9 EXCH.CODE: r 5 DRA'NN DATE: ENGR RUSS WELL Pt"TY:WASH r, PHONE FILE: SCALE 1_1TAX DISTRICT: 0`,YG OF TtNNSHP: I I 'i GE�;Fr s�<:TyE Yf]4K iC71X+1'_'EL�!.':Y'I_t'r__n'c CR!]ER•'+J�:-9VL:3 �-1?TLInY^C 111'"�RG,I;I{R:JKf""91'a':�Y4:II ti M`.::I{�0:121+r CONSTRUCTION NOTE i I I 1-WORK ORDER-SERVICE ORDER DRIVEN *****OIDt"i-37964096-"DOR"""** TOTAL ALLOTTED HOURS COv1ACT SUPERVISOR If ADOITIONAI. M ITZY CARTER HOUR$ARE RE0007EDTO GPYPLETE PROJECT, CAP. X-TIME1 MAINT. 12437 SW HALL BLVD-APT 10 CREW 0 0 0 SPLICING 0 0 0 I i�::L'Y i'Jz?. 2-CITY/TIGARD PERMIT REQUIRED SW HUNZIKER ST ! n �_ .�h: rv-C:A =:os. =_-= o:anu-T ONLY 3-TRAFFIC CONTROL REQUIRED-FOLLOW CITY/TIGARD PERMIT RESTRICTIONS > C -N R`-CE -)A-- *** m i cons,�n�ric;a cors:1:�,= JOB SITE � I LABOR HOURS ¢ f ,.-- ^�r cans^=ocTlou SW SCOFFINS ST = nE_, ci SPLICE-C-8/M-0/X-0 A D. CREW-C-10/M-O/X-0 FRONTIER TO PLACE I ❑cotrr:w-r;c. CONSTRUCTION CONTACTS VICINTY MAP © LX"c' DAVID CARNLEY-971-940-9000 12 FIBER TAIL 500' SW BURNHAM ST JAMES STARTS-503-758-3119 12 FIBER DROP-250' �e�:•;�TG '-!uNi'::T?;-LTT-i Z"•ITY/TIGARD SCHEDULING CONTACT ACCT CODES- RYAN ROBERTS-503-643-3713 FACILITIES CONTACT ZfZl.ZO I MICHELE CRISMAN 503-643-0180 MATERIAL REQUIREMENTS I se= �oLs INSPECTION CONTACT SHEET 1 OF 2 RON SITTON 503-871-8065 **x`12 FIBER TAIL- NORTH -500' ENGINEERING CONTACT ° n ° RUSS WELLS 503-312-7330 ***12 PORT AERIAL TERM ******BUNDLED VIDEO WORK ORDER*** ``"'iF` ***12 FIBER DROP-250' 51351-5223739-43 POINT C_ CONTACT RUSS WELI-S ********OID#37964096-"DOR"************* 503-043-1001 ** I sC^u_,ui±a LG RYANRP3ERT$ MITZY CARTER � n,•r= 503•C+�3.3„� 12437 SW HALL BLVD i I:Gira- RUSS:+-1005 Pp:r.r_ rin, 503•6413.1001 CBR#503-383-4904 �:”-'DED 51_RU�5,5 l�'VrLI S ASSIGN-FDT 361202 er, JFO H 1004,136 C ar music-tion j TGRD/37964096-"DOR" 12437 SW HALL BLVD PROJECT IC-0-AREA: 041-51351-5223739-43 �NunraER Exc r.coos: DRAWN DATE: ENGR: RUSS WELL.NTY: WASH 041-51351-W0644449 SCA E: PIAX ID ST-ICT: i?' MIG OF TV=NSHP: RNG: SEC: