Loading...
PFI2020-00074 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT a COMMUNITY DEVELOPMENT Permit#: PF12020-00074 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 03/04/2020 Parcel: SEG1028 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: PGE Job#M2751711 Project Description: SEG1028, 1085, 1497//14800 SW Scholls Ferry Rd(tower). Replace flashed over bells. Insulators will be replaced on existing structures. Class of Work: FEES Description Date Amount Type 1 -Utilities(gas, electric,data) PFI Permit Fee 03/04/2020 S300.00 Owner: Total $300.00 REQUIRED INSPECTIONS Call 503-639-4175 for the IVR inspection request line or visit the City of PHONE: Tigard website at www.tigard-or.gov to schedule inspections online. Contractor: PHONE: Applicant: LINDA OTT 2213 SW 153RD DR BEAVERTON,OR 97003 PHONE: 5036126093 Please sign below to indicate acceptance of conditions and return a copy with the proposed work schedule along with names and contact information of responsible parties before beginning work. Permittee/Applicant klt d ff p��G`v Signature: J J`!�/1 Nl_' jY�1, li� Issued By: A'e "tj Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12020-00074 Tyne: Condition Name: Status: Severity: PFI_Utilities 01 -WORK SITE REQUIREMENTS Applied Notice Applicant must comply with all applicable provisions of federal and state law,the Tigard Municipal Code,and the terms of any agreement with the City of Tigard regarding work to be done pursuant to this permit. PFI_Utilities 02-WORK SITE AREA Applied Notice The work area and approach roads shall be maintained in a clean condition,free from obstructions and hazards. The spreading of mud or debris or storage of materials or equipment of any kind upon any public roadway is strictly prohibited and violation shall be cause for immediate cancellation of the permit. The City may at any time order immediate clean-up and suspension of work to accomplish clean-up. PFI_Utilities 03-WORK SITE EROSION CONTROL Applied Notice Prior to starting work,effective and approved erosion control devices must be installed and maintained meeting the Clean Water Services and DEQ requirements. The City may at any time order corrective action and suspension of work to accomplish effective erosion control. PFI_Utilities 04-WORK SITE REPAIRS Applied Notice Disturbed landscaped areas shall be restored or replaced. Existing signs, pavement markings,mailboxes,etc.shall be reinstalled or replaced,with like kind of material.Obtain City approval of restoration work. PFI_Utilities 05-TRAFFIC CONTROL SPECIFICATIONS Applied Notice Applicant shall provide traffic control according to the current edition of the"Manual on Uniform Traffic Control Devices [MUTCD]for Streets and Highways", U.S. Dept.of Transportation, FHWA,current edition,American Traffic Safety Services Association[ATSSA],and Oregon Temporary Traffic Control Handbook[OTTCH]. PFI_Udlities 06-TRAFFIC CONTROL PLAN Applied Notice Submit a job specific traffic control plan. A copy of the approved traffic control plan shall be readily available at the work area.Traffic control devices,flag persons,etc.,shall be in place prior to initiation of construction work and shall be effectively maintained. PFI_Utilities 07-TRAFFIC CONTROL ROAD CLOSURE Applied Notice Public roadway shall not be closed to traffic,at any time,without obtaining written approval from the City Engineer. The applicant is responsible to provide 48 hour advance notice of traffic flow disruptions to affected businesses,residents and area wide Emergency Services:503-629-0111 (Tigard Police Dept.,Tualatin Fire&Rescue)and to 503-962-8140(Tri-Met) and 503-431-2345(Tigard School District)and other service providers impacted by such closure. PFI_Utilities 08-TRAFFIC CONTROL ADVANCE WARNING Applied Notice Advance warning of traffic disruption shall be provided to the public by placement of an approved advance notification sign at each end of the construction area 72 hours(min.)before initiation of construction work. PFI_Utilities 09-TRAFFIC CONTROL PROPERTY ACCESS Applied Notice Access to existing properties shall be maintained at all times,including normal delivery service and mail service.Obtain City approval of any access closures. PFI_Utilities 10-TRAFFIC CONTROL WORK HOURS Applied Notice Work is permitted in daylight between the hours of 7:00 a.m.to 7:00 p.m. Mon-Fri unless otherwise authorized by the City. PFI_Utilities 11 -TRAFFIC CONTROL LIMITED WORK HOURS Applied Notice Hours of construction work on collector and arterial roads will be limited to 9:00 a.m.to 3:00 p.m.unless authorized by the City Engineer. Work will not be permitted on collector and arterial roads between 3:00 p.m.to 9:00 a.m.unless authorized by the City Engineer. PFI_Utilities 12-TRAFFIC CONTROL MODIFICATION Applied Notice The City reserves the right to add to or modify traffic control requirements as necessary to effectively control traffic and to assure public safety. PFI Utilities 13-DRAINAGE CONTROL Applied Notice Drainage shall be controlled within the work site and shall not adversely affect adjacent private property,public property and the receiving system. The City may at any time order corrective action and suspension of work to accomplish effective drainage control. PFI_Utilities 14-UTILITY NOTIFICATION Applied Notice Oregon law requires following the rules adopted by the Oregon Utility Notification Center. Said rules are set forth in OAR 952-001-0100 through OAR 952-001-0080. Copies of said rules may be obtained from the Center by calling 503-246-1987. If you have any question about the rules,contact the Center. NOTE: Damage to utilities shall be corrected at the permit holders expense. PFI_Utilities 15-UTILITY LOCATION CONFLICT Applied Notice Applicant must verify all existing utilities for both vertical elevation and horizontal location prior to start of work(pothole before digging if necessary). Should conflicts arise and redesign or relocation of facilities be necessary,it shall be done at the applicant's expense. Changes must be approved by the City in advance of work.Applicant shall coordinate the work with affected utility agencies. PFI_Utilities 16-TEMPORARY PATCH Applied Notice A temporary hard-surface patch shall be placed on trenches within roadways at the end of each work shift. Obtain advance approval of patching method. No trench shall be left at any time in an un-safe condition. Applicant is responsible for and is liable for hazards or damage resulting from the prosecution of the work. PFI_Utilities 17-REPAIR OF EXISTING FACILITIES Applied Notice Work under this permit shall include repair of existing facilities(roads,ditches, etc.)as may be necessary,as determined by the Inspector,to overcome deterioration or damage which occurred in conjunction with the work authorized by the permit. Corrective work shall be done at the applicant's expense. PFI_Utilities 19-PRECONSTRUCTION MEETING Applied Notice Before initiating any construction activity,the applicant shall coordinate with the City's inspector, <Insert Name>at<Insert Phone#>,to establish a preconstruction meeting. PFI_Utilities 20-NOTICE TO COMMENCE WORK Applied Notice The applicant shall notify the City's Inspector twenty-four(24)hours prior to commencing work,prior to any staged inspection,and after completing work covered by the permit. PFI_Utilities 21 -PERMIT/PLAN ON SITE Applied Notice A copy of the permit including a Certificate of Insurance,and all attachments,and a copy of the approved construction plan and all amendments shall be readily available at the work area. All work shall conform to the permit terms,conditions and provisions and to the City approved permit plans,and approved plan amendments and to the City's standards and specifications and to these General Conditions. Changes to any of these must be approved by the City, in advance of work performance. PFI_Utilities 22-DAILY INSPECTION REPORTS Applied Notice Applicant shall submit daily inspection reports,on a weekly basis,to the City's Inspector. PFI_Utilities 23-MONUMENT PROTECTION Applied Notice Existing monuments,property corners,and survey markers shall be protected. Replacement shall be at the permit holder's expense. PFI_Utilities 24-VALIDATION OF MATERIAUCONSTRUCTION Applied Notice The City's Inspector may,at his discretion, require tests and or reports from the applicant to validate claims of material or construction adequacy/compliance. Such tests/reports shall be provided at the applicant's expense. PFI_Utilities 25-EMERGENCY CONTACTS Applied Notice Provide to the City inspector,in writing,the names and 24 hour emergency telephone number of two(2)persons who have authority to resolve problems,take corrective action and, in general,will be responsible in case of any emergency. The applicant shall notify the City Inspector,in writing,of any/all assignment changes. PFI_Utilities 26-RIGHT OF ENTRY/EASEMENTS Applied Notice Applicant to obtain proper right-of-entry and/or easements prior to starting work. Proof of right-of-entry or properly executed easements,shall be provided to the City. The City shall in no way be construed to be liable for the applicant's failure to obtain or provide for proof of right-of-entry or easements. PFI_Utilities 27-PRIVATE PROPERTY AGREEMENTS Applied Notice Provide the City a copy of an executed agreement[s]from the owner for each private property disturbed by construction activity. PFI Utilities 28-AS-BUILT DRAWING Applied Notice 12,345 28-AS-BUILT DRAWING One as-built drawing showing all new public improvements, including any revision made to the previously approved construction plans and,also,any improvement which may impact an existing public system or facility,shall be provided to the City by a registered civil engineer along with an engineer's certification of installation compliance(Certificate of Compliance). 1,2,3,4,5 28-AS-BUILT DRAWING One as-built drawing showing all new public improvements,including any revision made to the previously approved construction plans and,also,any improvement which may impact an existing public system or facility,shall be provided to the City by a registered civil engineer along with an engineer's certification of installation compliance(Certificate of Compliance). One as-built drawing showing all new public improvements,including any revision made to the previously approved construction plans and,also,any improvement which may impact an existing public system or facility,shall be provided to the City by a registered civil engineer along with an engineer's certification of installation compliance(Certificate of Compliance). PFI—Utilities 31 -OTHER Applied Notice Other RECEIVED c� City of Tigard FEB 2 7 2020 PFI#: ENGINEERING DEPARTMENT CITY OF TIGARD PLANNING/ENGINEERING Public Facilities Improvement (PFI) Permit PROJECT INFORMATION 'TYPE OF WORK Project name: PGE Job # M2751711 B TYPE 1—Franchise Utility Work Brief description of project: REPLACE FLASHED OVER BELLS performed byNWN,PGR, or utility agency insulators will be replaced on exisiting structures ❑ TYPE 2—ROW Sidewalk/Driveway/Sewer Work performed for the purpose of. • Sidewalk installation or repair • Driveway approach installation and repair SITE INFORMATION • Sanitary sewer lateral installation and tower 1/2 15035 SW Kingbird DR main line tap Location (address if available): g (tower) LiTYPE 3—Full Scale Development Work 1/3 14800 SW SCholls Fry Rd (tower) ' �� �Q� ��1T performedwith land use approval which includes any of the following. • Subdivisions or Partitions APPLICANT INFORMATION • Streetwidening Name: PGE Linda Ott • Mainline installation for sanitary sewer, storm sewer, Tigard water, and Tigard Mailing address: 2213 SW 153rd DR water service area City/State: Beaverton, OR Zip: 97003 ❑ TYPE a-Small Cell Technology Phone: 503.612.6093 ❑ TYPE 5—Tigard Triangle Email: preregcoord@pgn.com Phone: NOTE: Type t and 2 applications may be 9 Contact name: Kevin De Angelis emailed to=owpennits(r�.tit;ard-°=.,�ov Phone: 503-736-5414 Ems: preregcoord@pgn.com CONTRACTOR INFORMATION ❑ Same as applicant Name: Pge Crews CCB Number: Mailing address: City/State: Zip: Phone: 503.464.7777 Ems: ENGINEER INFORMATION Name: Mailing address: City/State: Zip: Phone: Ems: ADDITIONAL INFORMATION Estimated value of work is required(if over$5,000):$ (within the public right-of-way) Is work related to a LAND USE DECISION? ❑Yes ED No Case number: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.fgatd-orgov 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 15.04.140. * With the exception of a utility operating pursuant to a valid franchise or license with the City of Tigard,when the owner and the applicant are diffrnnt 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 must sign this application in the space provided or submit a written authorization with this application. Franchised or Licensed Utilities are not required to obtain the owner s signature on the application. I,the applicant,certify that: • To the best of my knowledge,all the information provided within this application package is complete and accurate. • The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject property. • If the application is granted,I will exercise the rights granted in accordance with the terms and subject to all the conditions and limitations of the approval. � M Linda oft for Kevin Deangelis 2.27.20 Applicant's or authorized agent's signature Print name Date Property owners signature (if required) Print name Date STAFF USE ONLY Case No: Permit fee: 30D'V Received by: Date: Approved by: � ''j� Date: aIt3IZ Notified by: 04 Date: - 3W-City of Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-ozgov • 503-718-2421 • Page 2 of 4 DEVELOPMENT ENGINEERING FEES Public Facility Improvement(PFI)Permit: INITIAL PFI PERMIT FEE Part 1: Required submittal fee is 10%of the Net PFI Permit Fee.See below for calculations.Minimum of$300. NET PFI PERMIT FEE Part 2: All non-water system improvements engineer's estimate X 7%(less the initial PFI Permit Fee). WATER LINE CONSTRUCTION FEE Part 3: All public water system improvements engineer's estimate X 12%. FOR ONLY ONLY SUBMITTALTYPE 4: SMALL WIRELESS FACILITY TYPE 1-3: DETAILED CHECKLIST REQUIREMENTS Does applicant have a right-of-way license? ❑Yes ❑No TYPE 1 AND TYPE 2-Must include a sketch showing: Under the wireless facilities standards,is the proposal ❑ Dimensions considered?(check all that apply): ❑Small Cell ❑Macro ❑ Street Name How many install sites are proposed as part of this permit ❑ Site Address application? TYPE 3-Must provide 4 sets of plans (sized 24 x 36 or 22 x 34) and an electronic version of all submittal The proposed equipment is located on which of the following. items. The plans must that include: ❑Public Right-of-Way ❑Private Property ❑ Cover—Site,Vicinity,Abbreviation,Legend If equipment is to be located on private property,describe the ❑ General Notes(City,Water,Sewer,etc.) type&use: ❑ Street(Plan,Profile) ❑ Water,Storm and Sanitary(Plan Profile) ❑ Water Quality Facilities ❑ Grading ❑ Landscaping/Tree Plan ❑ Composite Utility Plan(Electrical,Phone,Gas, Storm, Sanitary,Water,Signage,Street Lights,etc.) ❑ Details ❑ Traffic Sight Distance ❑ Signing and Striping ❑ Street Light Plan and Photometric ❑ Engineers seal/signature ❑ Sheet label(project land use name,revision and plan log block,dates and sheet numbers.) ❑ Engineers Construction Estimate Additional Submittals (per land use conditions,if applicable) ❑ Traffic Report ❑ Storm water Drainage Calculations ❑ Geotechnical Report ❑ Preliminary Access Report(Sight Distance) ❑ Proposed Plat ❑ Pathway Design ❑ Water Provider Approval City of Tigard 13125 SW Hall Blvd. Tigard,Oregon 97223 • www.figard-or.gov • 503-718-2421 • Page 3 of 4 Edge of Pavemnit L)itch Streetlight 1 —•---------•— —r—•— Rdn Dnk, I 1 0:• 1 i T'pr otos elwSrTiRe W 1 a Existing House 1 Existing 1 .I I Driveway dl I U� I 1 ZD. a`i ,lie 1 jp W of I 1 ExiMing Shop j J p 1 = I 1 Power ole I I la 95, 1 1 1Trop FFF Line------'---- ' O QI Fire Hytlrant(FH) � � I Scale' 1"=30' I i I TYPE 1 AND TYPE 2: MINIUM SKETCH REQUIREMENTS (Put N/A if not applicable) I I I ' 1 i North arrow Property lines&dimensions Existing utilities locations (sewer, storm,water) Street&street names All existing structures Proposed work Existing curb or edge of pavement Utility&street light poles Existing S/fix'or D/W apron Slope of property 'frees City of Tigard • 13125 SW I Iall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov - 503-718-2421 - Page 4 of 4 www.invarion.com Poles 4600&436 NE 188th Ave ' 01' td'.c Page U Stationary Lane Closure with Flagging Diagram 320 iIt 0 _ - 4t 77 i I �_ ■ I Provide a to I �■ � assist pedestrian traffic I I ' safely around work area Ia I when a safe detour route I V J. I • � Is not avala6le. I I I + ik!'> I V I IB I fq j t o_ I Stan 5 acro and 9utier Ler the feet' V-- Potted s xi Be1wdrn5i fu '9u119^ I t Speed A 8 c Sp { 20 50 66 25 180 100 104 75 30 100 35 US 30 350 350 354 150 35 18C 50 500 500 500 ilc 55 I G v0 2!5 65 700 T00 70C 315 70 365 www.invarion.com Pave 84 2U11 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 AUT". 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. T he "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. Cnaptu S September 2016 www.invarion.com 2011 Eda on Page 53 Bicycle Accommodation Diagram 5.8 I I I I NOTES: . Brcydes on Roadway(CW11-1)sign should not Interrupt standard sequences. For example: 1 c BE PREPARED TO STOP/Fla Symbol c I _LANE CLOSED AHEADILannEnds I Symbol 1 + Skyctes on Roadway sign typically follows ROAD I WORK AHEAD sign and used as general warning. I I I I I I I I I I I I A I I I I I I I I I I A I I I I I I I � I I B I I I I lit I IB t I I I I 1 C I I 1 R I WORK AHEAD M September 2016 Chapter 5 www.invarion.com f'a�e t 2 2011 Edition Bicycle and Pedestrian Accommodation Diagrams the following practices and details address the accommodation of bicycles and pedestrians within work zones. The following detail drawings should be incorporated. where appropriate, into the traffic control plan for any short term work. 1. See Section 1.6 — Bicycle and Pedestrian Considerations for additional guidance. 2. Stay alert for pedestrians and bicycle traffic and accommodate safe passage for them. as needed. 3. 1 he work space should be protected from bicycle and pedestrian intrusion by using barricades or closely-spaced channelizing devices. 4. Maintain access to transit stops or clearly close a transit stop using barricades or channelizing devices Bicycle Accommodation Diagram 5-6 Bicycle Accommodation Princiotes: 1 If a significant volume of bicycles can be expected and work closes a marked bicycle facility, or requires bicycles to share a travel lane. install a "(Bicycle) ON ROADWAY" sign (CW 11-1) or the Bicycle symbol (W11-1)sign with an "ON ROADWAY (OBW1-5) rider, in advance of the work area. 2. Install temporary signing off the paved shoulder, within the planter (buffer) strip, or share the width needed between the shoulder and the sidewalk. as available. 3. Signs are to remain in place until the surface is restored and the width made available for bicycle use See Diagram 5-6 for typical bicycle signing placement Sign 5paci_ng and Buffer Lengths(feet) Postal Spadfl BetwownsLm .kftrl. sP"41 ___A__T__a__F__c7 spam 2c so 25 100 loo too 75 30 100 35 3i0 350 350 125 d0 ISO __45 Igo 50 500 S00 500 210 55 250 60 285 65 700 700 700 325 70 36S chapter 6 September 2016 _ .i C11-27 C11-34 C21-03 C21-10 C2 `� C21-22 tea\ C21-27 C21-34 C3UP Transmission Line T6J 230KV MURRAYHILL-SHERWOOD#1 Page 2 of 5 > Date:7/15/2016 C11.21 ! C71-29 Cit-33 C21-04 �.�_ '"�-- - -._Yr C21-09— C2"# __ C U . ` 4021-28 02133 ^ C31-oa U9.nE j •� 4 t� / •• neM..lon Croeke ! _ — W tons_ —T n.mmbnc!rt R �l n.ar PGE � 1 v r 0%e,ME OESIbn GM \ County — 21-29 i' Af a n..w cewn 011.20 011.29 C11.32 C21.05 C21.08 � 1 R.. ... 021.17 C21-20 1 i' 021-32 ! \ SHERWOO ' C3145 ,.,.E,,..,..Il...�W,r.. $Il@fWOOA MW.n.p.ry E9RI woM.gnIf OC�q,ly.f.Nwq Gam,*[Eimr. _ �' SIX CORNERS 021-06C'HOLL - fel ■ .a..xo...r.�...�...M.rr.a«....�,.•mw••�.•..,:....n..... zC1 C1130 I,_ - C11-31 ■ C21-07 021-1t 027.19`.Ch/cn C2^-3C 021 ri 'C a C31.O6 w'+^' ""�^w°""`•^°^..... ••^0.°'"•::`•�"w �`�s`�::�^^"^"_.,,.., o 23. .aao v.ew I.A. FW D 9362 - - 9368 -.. 704$. 175 5 -_ - 9361 e 6545 3 � •e 9365 654S ' ,; 9388. -_�- ... • ._., .. '. 9364...: .. - 9370 80 z U. soo Cll-22 C11-27 t Cll-34 C21-03 C21-10 C21 Transmission Line It 66 C21-22 C21-27 C21-34 C31-03 •O. Page 1 of 5 Date W1512016 �CZI-28 C21-33 C31-04 Legend � j PGE MURRAYHI County 21-29 M.,PGE CII-20 1-32 7 it—I •ue 0��- CORNERS e ' �..� _';. M.r. v�� f,� _ �.'�y4��rn/ n .-ate �• . - 1r4W r �`V • r _ - w .IJ x ` Va . t a NK' r0- \` r � � •-�r..•�M •��. l.i16f `� Q i�. ",•Y Tw _ �� � fid© !• "`°+i qrf,��,,. /S, �, \ !� -., 1 L - ' 6''•e is `► 1� f� � a ' .+a,�„ ,1'•�'I j�,, 4w e City of Tigard March 9,2021 PGE 10800 SW Avery St Tualatin, OR 97062 Re: Permit No. PFI2020-00074 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: Street segment SEG1028/1085/1497 Project Name: PGE Job No.: M2881038 Refund Method: ® Check#238570 in the amount of$240.00. ❑ Credit card"return"receipt in the amount of$ Note: Please allow 2-5 days for this refund transaction to be credited to your account by the company that issued your card. ❑ Trust account"deposit"receipt in the amount of$ Comment(s): Per applicant's request as job was cancelled. Refund 80% of application fees as permit was issued. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Omelas Building Division Services Supervisor Enc. 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171 TTY Relay: 503.684.2772 0 www.tigard-or.gov a ° City of Tigard Accela Refund Request This form is used for refund requests of land use, development engineering and building permit application fees. Receipts,documentation and the Request for Permit Action form (if applicable) must be attached to this request form. Refund requests are due to Accela System Administrator by each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts Payable will route refund checks to Accela.System Administrator for distribution to applicant. PAYABLE TO: PGE DATE: 3/1/2021 10800 SW Avery St Tualatin, OR 97062 REQUESTED BY: Dianna Omelas AL TRANSACTION INFORMATION: Receipt#: 428476 Case#: PFI2020-00074 Date: 3/4/2020 Address/Parcel: SEG1028/1085/1497 Pay Method: CreditCard Project Name: PGE EXPLANATION: Per applicant's request as job was cancelled. Refund 80%of application fees. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 2300000-43104 $Amount PF1 Pcrmit FCC 640-0000-43114 5240.00 TOTAL REFUND: $240.00 APPROVALS: SIGNATURES/DATE: If under$5,000 Professional Staff If under$12,500 Division Manager If under$25,000 Department Manager If under$100,000 City Manager If over$50,000 Local Contract Review Board FOR ACCELA SYSTEM ADMINISTRATION USE ONLY Case Refund Processed: Date: Bv: L\Building\Refunds\RefundRequescdoc x 09/01/2010 CITY OF TIGARD RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 Project Name: PGE Job#M2751711 Site Address: -7 z -��J J Receipt Number: 436251 - 09/04/2021 �`'� CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12020-00074 $-240.00 Total: $-240.00 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 238570 DHOWSE 09/04/2021 $-240.00 Payor: PGE Total Payments: $-240.00 Balance Due: $240.00 Page 1 of 1 CITY OF TIGARD RECEIPT 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Project Name: PGE Job#M2751711 Site Address: Receipt Number: 428476 - 03/0412020 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12020-00074 PFI Permit Fee 640-0000-43114 $300.00,,— Total: 300.00LTotal: $300.00 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 6131726 PUBLICUSERO 03/04/2020 $300.00 Payor: Total Payments: $300.00 Balance Due: $0.00 Page 1 of 1 V City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT = r Request for Permit Action 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.6gard-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPennitsQtigard-or.gov FROM: ❑ Owner Applicant ❑ Contractor ❑ City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or lndiyiduaD Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): CANCEL/VOID PERMIT APPLICATION.—I TR AL. INI u-&,( REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). Permit#: kD 1-DW -CM-7¢ Site Address or Parcel#: S'CG i o2a I i 085 Project Name: P&e Subdivision Name: Lot#: EXPLANATION: TCAo V\rA$ CAACLLUA /Z-g nit� k'00Zo f1-S ►°EV-1-tl-C CA; /t-s lsscL-� � Signature: Date: Print Name: eS "1Jt71- 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. -2O O t a y o ,07) FOR OFFICE USE ONLY Route to Svs Admin: Date B Route to Records: Date Z By AO Refund Processed: Date 31'1Z1 J0, IInvoice Processed: Date B Permit Canceled: Date /12.117.01 BWO I Parcel Ta added: Date B 1:\Buikling\Forms\RegPermit,kction_1 518. c Agnes Lindor From: Denise Choin <denise.choin@pgn.com> Sent: Wednesday, May 27, 2020 10:30 AM To: ROW Permits Subject: Canceled job Caution!This message was sent from outside your organization. Allow sender I Block sender Hello, PGE Job M2881038, 1/2 15035 SW Kingbird DR (tower), was issued your permit PF12020-00074. We have canceled this job. Thank you for your time and effort. We will make every effort to notify you when we cancel jobs. If you have any questions, please let me know. Denise Choin / Administrative Assistant, Pre-Requisite Line Dept• 503-612-2851 10800 SW Avery St.,Tualatin,OR 97062 PortlandGeneral.com • Follow us on social @PortlandGeneral 1