The URL can be used to link to this page

PFI2018-00191 VOIDED PF12018 00191 VALVE REPAIR City of Tigard e COMMUNITY LllI:NTFLOPMENT DEPART"HENT e = Request for Permit Action 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • wwtv.tigard-or.gc 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 ecity Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) 4:5 G� Mailing Address: k, 4 Ala City/State/Zip: ©�" .�—E�►Gj �� 9�� Phone No.: ��d� 22� 1211 X, -3 T7 7PLE E 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#: Z�� 2aztf ^' Site Address or Parcel #: 2 1�q"- Project Name: Subdivision Name: Lot#: EXPLANATION: Signature: Date: f 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. FOR ONLY Route to Sys Admin: Date B Route to Records: Date B Refund Processed: DateB Invoice Processed: Date B Permit Canceled: DateW2314.doc B Parcel Ta Added: Date B I:\Building\Forms\RegPermitAction_ V D City of Tigard RECEIVED and P /� �� g � � PUBLIC 1X!0RKS —ENGINEERING JUL 19 2019 s Public Facility Improvementr (PF, 111, , G i v TYPE OF WORK DESCRIPTION OF WORK(in the right-of-Nvay) ❑ TYPE 1—Franchise Utility Work Check one: 0 Utilities ❑Sidewalk/drive«-ay approach 0 Streetimprovements performed by N\X,N, PGE $ency. l and/or Utility a Detailed description: Maintenance to make valve available and operable at the intersection an of SW Scholls Ferry and 121 st Ave.Valve is on the 23'in ROW from the El TYPE 2—Sidewalk/Driveway/Sewer centerline. One 2'x 3' hard surface cut needed.TCP attached. Work performed for the purpose of: • Sidewalk installation or repair. SW Scholls Ferry and 121st Ave • Driveway approach installation Property address/location(s): ry and/or repair • Sanitary sewer lateral installation and/or main line tap Applicant: NW Natural/Shelly Kirsehenman ❑ TYPE 3—Full scale Development 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 x4347 Email: smk@nwnatural.com • Subdivisions or Partitions Contact name: Shelly Kirsehenman Phone: • Street widening • Mainline installation for Sanitary Lo Clark/Jade Leed sewer, Storm sewer, Tigard water Contractor: Y Y and/or Tigard Water Service Area CCB#: 52281 Expiration: Address: PO Box 1369 SUBMIT COMPLETED APPLICATION TO: City/state: Troutdale OR Lip: 97062 City of Tigard Planning/Engineering Phone: 971-806-2841 Email: 1ade.leedYto clark.com 13125 SW Hall Blvd. Contact name: Jade Leedy Phone: Tigard,OR 97223 Applications for"minor work in right-of-\vay" En 'neer: Richard Girard only may be emailed to: g rowpermitsCd�tigard-or.gov Address: Same City/state: Zip: FOR STAFF USE ONLY Phone: 360-921-0314 Email: r2g@nwnatural.com Case No.: 25LW10— Contact name: Application submittal fee(.007%of Engineer's Estimate) $ Estimated Value of work is required(if over$5,000):S Additional fees: 0,vithin the public right-of-way) Application accepted: Is work related to a LAND-USE DECISION? ❑ Yes ❑ No By:— Date: If so, please specify (MLI?SDR, SUB, etc.) case #: Application reviewed: By: Date: Is work related to a BUILDING PERMIT? C7 Yes ❑ No Applicant notified: If so,please specify(BUILDING PERMIT)case#: By: Date: I:\ENG\PermitApplications\pfi_application Rev.10/16/2017 City ofTigard • 13125 SW 1 fall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 1 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 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 ani,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 Shelly Kirschenman p n m a DN:cn=Shelly Klrschenman,o=NW Natural,ou, email=smk@nwnalural.com,c=US Shelly K I rS C h e 1 1 1 1 11..E n 7/19/18 Date:2018.02.14 08:31:35-08'00' 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 ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwagard-or.gov 503-715-2421 • Page 2 of4 SAMPLE SKETCH: y S W .9 t, Edge of F w7ement I Ditch � r} Streetlight I .—.--.---.----.—.—r—.— �' F.�,Driin 1 I C= G 1 T"'ITr o'p as cfSow 0� rT n F" I I - I Q.) No Existir^ig House Existing • I >I Driveway 1 I E' I W 01 GL I � L1 ' �I I , ,$ 1 IU s °'' I 1 " I Existing Shop A C J Powerpole 1 O 776perW Lrne- I , ! Fire Hydrant(FH) I I I Scale: 1-=30' I � � 1 I I I 1 I I I I I I � 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 ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www:tigard-or.gov • 503-718-2421 Page 4 of4 i DEVELOPMENT ENGINEERING FEES FOR STAFF USE ONLY Public Facility Improvement(PFI)Permit: DETAILED SUBMITTAL APPLICATION FEE REQUIREMENTS Part 1: Required submittal fee$300.00 (minimum) FRANCHISE UTILITY AND SIDEWALK/ DRIVEWAY AND UTILITY PERMIT FEE CONNECTIONS,ETC. Part 2: All non-water system improvements (work in the right of way) Engineer's estimate X 5%(less$300.00 minimum submittal fee) Sketch Engineer's estimate X 2%Plan Review (including information below) ❑ Dimensions WATER SYSTEM FEE ❑ Street Name Part 3: All public water system improvements ❑ Site Address Engineer's estimate X 12% FULL SCALE DEVELOPMENT PFI Permit Fee Exemptions: (Subdivisions/Partitions and Street Improvements) There will be no permit fee charged,or assurance required for the following types of work: Design Plans • Sidewalk repair(less than 20 lineal feet) (G sets,24x36 or 22x34) • Relocate or replace mailbox ❑ Cover—Site,Vicinity,Abbreviation,Legend • Ditch cleaning that does not involve regrading. ❑ General Notes(City,Water,Sewer,etc.) • Weep hole repair ❑ Street(Plan,Profile) • Curb repair or replacement(less than 20 lineal feet) ❑ Water,Storm and Sanitary(Plan Profile) • Lawn sprinkler system installation or repair ❑ Water Quality Facilities • Street tree pruning or planting ❑ Grading • Planter strip landscape maintenance ❑ Landscaping/Tree Plan • Test wells ❑ Composite Utility Plan(Electrical,Phone,Gas, Storm,Sanitary,Water,Signage,Street Lights,etc) ❑ Details Note: A cash/bond assurance maybe ❑ Traffic Sight Distance required per TMC 15.04.140. ❑ Signing and Striping (customer deposit) ❑ 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 ❑ Engineer's Construction Estimate PUBLIC FACILITY IMPROVEMENT PERMIT City ofTigard 13125 Ste'Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov 503-718-2421 • Page 3 of4 a a _=' Position A . � X 1410017 y 656556 PIP Latitude 45.44429719 Lonaitude •122.80018278 10 Plat 1-041.017 County WASHINGTON City BEAVERTON Tax Code 051.58 _Taxing District ; NULL Township T01S Ranae R01W Ir- Section 34NW _ Route uptions-- r OK _ ♦ N -- \♦ �Ci 'tir 7t i • l t• sw Ig of Ig lip • tF i% 1 •- Or i .. R 1 1 •w ,• a �v,� 0 Position J x 1410019 54 Latitude 45.4442918604Makepaved over valve available tooperate er Adam platLongitude -122.80017476 � p Cou 1-041-017 7 Ortega. must operate; by 8/31 /18 for compliance County WASHINGTON City BEAVERTON Tax Code 051.58 c Taxina District NULL Townshio T01S Ranae R01W n Section - ZAAIW ITL Route Options---- OIL FILTER Q 161' VESSEL 00 SLIJ c TER ` L 2 n 6518(�N 6"P4 � �s N K&D Services,as the preparer of this traffic n Page 2 of 2 control plan makes no representation as to its' ROAD �� 350' WORK WORK gene adequacy uac or bein a roved for im lementation. AREA i R AREA g q Y g PP P D 350' E Spacing { Approval must result from the Traffic Engineer or 3539630 PP g �, Spacing ; other Public Official having statutory enforcement authority 4 in the jurisdiction. Utilization and implementation of this plan shall be a result of that approval. ' Ref.MUTCD 2009 6A-01(10) ' Z Lane Width 12' p, Posted Speed 40mph 350' 4_ Merging Taper 325' Spacing \ Buffer 150' Sign Spacing 350'+/- �� cho\\sFet�Y Devices Taper 40' _ _ Devices Tangent 40 ' - �I NOTTO�SCALE NOTIFY EMS,FIRE AND POLICE /R 72 HOURS IN ADVANCE NOT TO SCALE) r r. CUSTOMER: • 4 3 NWNG • • • �� CONTACT: ' Andy Cook (503)226-4211 x 6963 / O 1.Maintain Ped.access to LOCATION: and through crosswalks SW Scholls Ferry Rd & 121 st Ave n Ve n to ry. and or sidewalks. 2.Maintain Min.10'lane Beaverton, OR 3.Maintain Local access Road Work Ahead 4.devic shall ontrol nywith and all - devices shall comply with the DATE: W/O# 2009 MUTCD and OTTCH 2011 07/19/18 3539630 1 - Left Lane Closed Ahead standards. PLEASE SCHEDULE 5.Device spacing: 1 - Double Transition (Right) Flag taper 20' WITH DISPATCH Designed By: � All other tapers equal to the �f �f p-f r* posted speed.20'min.for tangent @ 503-723-720 7 0 6.28"cones i1 1 - Arrow Board 3 36"barrels 4 DAYS IN ADVANCE - John Smart r 48"signs wl Flags 7.Cover stop signs and/or disable AND PROVIDE A K tst 0--.-S LRVID EF; Off. 503-723-7287 1 - Double Arrow CD lights when at a controlled intersectionCOPY OF THE APPROVED �""'° MANAGC MCMT I. Place No Parking signs 48 hrs in advance. Ext. 1015 30 - Cones 9,Adjust t°`eld`ond`tions. TRAFFIC CONTROL PLAN ORTCP@KNDSERVICES.NET CROSS SECTION DETAILS Paving Symbels: AC-Asphalt E-Earth C-Concrete G-Grave! PUE-Public Utility Easement,ROW-Right-of-Way, EOP-Edge of Pavement,C/L-Centerline c«rnw�6 WO#3539630 LU NORTHSIDE Paved over valve lid CURB! Y t N N CURB? Y r p 1 cL 1 1 1 2'z 3' 1 1 Hardsorface 1 1 1 1 Number of cuts diamond cat I Valve 23' off j S¢e of cut(s):: i centerline 1 Y Over main 1 1 1 Over other utilities 1 1 i SW SchoUs Fera,Rd. & 121st.Ave 1 1 Street Name: -- - - - 1 1 13' 1 53' 1 Direction Facing ` NorthWest AC 1 AC 1 F-8039 (6/30110)