PFI2020-00148 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PFI2020-00148
TIC,\R D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 04/22/2020
Parcel: SEG1676
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: NW Natural Valve Inspections. 3604953
Project Description: SEG3944, 2395, 2496, 3035, 1676, 2404, 2468//Various addresses, see attached.Annual valve
inspections at various addresses. No digging or cuts required. See attached for details.
Class of Work: FEES
Description Date Amount
Type 1 - Utilities(gas,electric, data) PFI Permit Fee 04/21/2020 $300.00
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.tioard-or.aov to schedule inspections online.
Contractor:
PHONE:
Applicant:
DAN HACKER
250 SW TAYLOR STREET
PORTLAND, OR 97204
PHONE: 5032264211
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
gyp ,
Signature:
Issued By: N
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PFI2020-00148
Type: 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_Utilities 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
holder's 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, Trent Brickey at
972-228-9269,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 MATERIAL/CONSTRUCTION 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
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).
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
City of Tigard APR 2 0 2020 PFI#: 2020 00148
_ ENGINEERING DEPARTMENIC11y OF TiGARD
TtGARD Public Facilitie f 'ifi 'a ali ent (PFI) Permit
PROJECT INFORMATION
TYPE OF WORK
Project name: 3604953 r; TYPE 1—Franchise Utility Work
Brief description of project: Annual valve inspections at various addresses. performed by NWN,PGE, or utility
P P 1 agency
No digging or cuts required. See attached for details. I-- 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
Various addresses, Tigard
main line tap
Location (address if available): 9
I— TYPE 3—Full Scale Development Work
SEG3944, 2395, 2496, 3035, 1676, 2404, 2468 performed with land use approval which
includes any of the following:
• Subdivisions or Partitions
APPLICANT INFORMATION • Street widening
NW Natural • Mainline installation for sanitary sewer,
Name: storm sewer, Tigard water, and Tigard
Mailing address: 250 SW Taylor St water service area
City/State: Portland, OR Zip: 97204 r TYPE 4—Small Cell Technology
Phone:
503-226-4211 x4461 E TYPE 5—Tigard Triangle
Email: djh@nwnatural.com Phone: 800-882-3377 NOTE: Type 1 and 2 applications may be
Contact name:
Dan Hacker emailed to rowpermits[ltigardor gov.
Phone: Same Email: Same
CONTRACTOR INFORMATION E Same as applicant
Name: Same CCB Number:
Mailing address: City/State: Zip:
Phone: Email:
ENGINEER INFORMATION
Name: Rich Girard
Mailing address: Same City/State: Zip:
Phone: 360-921-0314 Email: r2g@nwnatural.com
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 _No Case number:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • uww.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 15.04.140.
* 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 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 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.
Dan Hacker 4/17/2020
Applicant's or authorized agent's signature Print name Date
Property owner's signature Of required) Print name Date
SrAPF USE ONL1
Case No: PFI2020-00148 Permit fee: 5Oa.0V Received by: SC Date: 04-20-2020
Approved by: 7Fe/a7 Date: 2•P/LOZ/° Notified by: /' Date: 'ill(''W
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 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 STAFF USE ONLY FOR STAFF USE ONLY
TYPE 4: SMALL WIRELESS FACILITY TYPE 1—3:DETAILED SUBMITTAL
CHECKLIST REQUIREMENTS
Does applicant have a right-of-way license? I Yes No TYPE 1 AND TYPE 2-Must include a sketch
showing:
Under the wireless facilities standards,is the proposal
C Dimensions
considered?(check all that apply): Small Cell Macro I— Street Name
How many install sites are proposed as part of this permit
L 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:
I Public Right-of-Way I Private Property
L Cover—Site,Vicinity,Abbreviation,Legend
If equipment is to be located on private property,describe the L General Notes(City,Water,Sewer,etc.)
type&use: L Street(Plan,Profile)
L Water,Storm and Sanitary(Plan Profile)
L Water Quality Facilities
L Grading
L Landscaping/Tree Plan
L Composite Utility Plan(Electrical,Phone,Gas, Storm,
Sanitary,Water,Signage,Street Lights,etc.)
C Details
C Traffic Sight Distance
C Signing and Striping
C Street Light Plan and Photometric
C Engineers seal/signature
C Sheet label(project land use name,revision and plan
log block,dates and sheet numbers.)
I— Engineer's Construction Estimate
Additional Submittals
(per land use conditions,if applicable)
C Traffic Report
C Storm water Drainage Calculations
L Geotechnical Report
L Preliminary Access Report(Sight Distance)
L Proposed Plat
C Pathway Design
L Water Provider Approval
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 3 of 4
Edge of Pavement
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TYPE 1 AND TYPE 2:
MINIUM SKETCH REQUIREMENTS (Put N/A if not applicable)
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/W or D/W apron Slope of property Trees
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • v wwtigard-or.gov • 503-718-2421 • Page 4 of 4
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CUSTOMER: R40 es the prewar of thlS traffic 7.Maintain Pad.access to
NW Natural control plan makes no representation Legend and through crosswalks
as to its general adequacy or being and or sidewalks.
approved far Implementation.Approval 0 CONE
CONTACT: must result from the Traffic Engineer 2.Maintain Min.10'lane
Katie Liebert or other public official having mammy ®CW9-3 center lane closed ahead 3.Maintain Local access
503-226-4211 enforeemel4 authority In the 4.Traffic Control Plan and all
jurisdiction.Utilization and Finger devices shall comply with the
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SW 74TH AVE Ref,MurcD aeogo mini. *W20-1 road work ahead standards.
TIGARD OR S.DEVICE SPACING:
®W20-7A Flagger Ahead Flag taper 20'
DATE: WOO: TYPICAL ®W20-7b be prepared to stop All other tapers equal to the
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Plata: 7.Cover slop signs and/or disable
1447.022 lights when at a controlled
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advance.
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30 CONES
Samuel Copelan
From: Hacker, Daniel <Daniel.Hacker@nwnatural.com>
Sent: Monday,April 20, 2020 9:29 AM
To: ROW Permits
Subject: RE:Annual Valve Inspections-Various Addresses -WO#3604953
Caution!This message was sent from outside your organization. Allow sender I Block sender
Here is the list:
Approved
SW Roy Rogers Rd & Rock Hampton Ln SEG3944
9450 SW Durham Rd SEG2395
SW Durham Rd & SW 172nd Ave SEG2496
SW Upper Boones Ferry Rd & SW Durham Rd SEG3035
SW Gaarde St & Pacific Hwy S SEG1676
Not approved
SW Durham Rd & SW 85th Ave SEG2404
SW Durham Rd & SW 74th Ave SEG2468
Thanks!
Dan Hacker
NW Natural—Technical Coordinator 2
w: 503.226.4211 x4461 I nwnatural.com
From: ROW Permits<rowpermits@tigard-or.gov>
Sent: Monday,April 20,2020 9:10 AM
To: Hacker, Daniel<Daniel.Hacker@nwnatural.com>; ROW Permits<rowpermits@tigard-or.gov>
Subject:RE: [External]RE:Annual Valve Inspections-Various Addresses-WO#3604953
CAUTION: This email originated outside NW Natural. Please do not click links or open attachments unless you
recognize the sender and know the content is safe.
Hi Dan,
Please send a list of all 9 addresses and make a note of which ones have yet to be approved.
Thanks,
Sam Copelan
1
Assistant Planner
City of Tigard; Community Development
13125 SW Hall Boulevard
Phone: (503)-718-2450
Email: Samuelc(ti;tigard-or.gov
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."
From: Hacker, Daniel<Daniel.Hacker@nwnatural.com>
Sent: Monday,April 20,2020 8:27 AM
To: ROW Permits<rowpermits@tigard-or.gov>
Subject: RE: [External]RE:Annual Valve Inspections-Various Addresses-WO#3604953
Good Morning,
Would you like a list of all 9 addresses we currently have for Tigard or would you just like the 4 that
haven't been approved by you yet?
Thanks!
Dan Hacker
NW Natural—Technical Coordinator 2
w: 503.226.4211 x4461 I nwnatural.com
From: ROW Permits<rowpermits@tigard-or.gov>
Sent: Monday,April 20,2020 8:15 AM
To: Hacker, Daniel<Daniel.Hacker@nwnatural.com>
Subject: [External]RE:Annual Valve Inspections-Various Addresses-WO#3604953
CAUTION: This email originated outside NW Natural. Please do not click links or open attachments unless you
recognize the sender and know the content is safe.
Good morning Dan,
Would you please send me an address list of where the inspections will take place?I need to associate with the
permit with an address/ street segment.
Thanks,
-Sam
City of Tigard
2
Public Facility Improvement (PFI) Permits
Monday-Thursday 8am-5pm
Phone: (503) 718-2421
E-mail: rowpermits(a)tigard-or.gov
From: Hacker, Daniel<Daniel.Hacker@nwnatural.com>
Sent: Friday,April 17,2020 12:32 PM
To: ROW Permits<rowpermits@tigard-or.gov>
Subject:Annual Valve Inspections-Various Addresses-WO#3604953
Hello,
Please see attached (new batch of 2 TCP's) annual valve inspection permit request. Let me
know if you have any questions.
Thanks!
Dan Hacker
NW Natural—Technical Coordinator 2
w: 503.226.4211 x4461 I nwnatural.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
111
r
r
TIGARD
City of Tigard
August 13,2021
NW Natural
Attn: Dan Hacker
250 SW Taylor St
Portland, OR 97204
Re: Permit No. PFI2020-00148
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: SEG 2395
Project Name: NW Natural
Job No.: N/A
Refund Method: ® Check#240241 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 to cancel permit and refund 80%of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
*1214,t
Dianna Ornelas
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
11111
City of Tigard
r c n Ei a 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: NW Natural DATE: 8/6/2021
250 SW Taylor St
Portland, OR 97204 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 429084 Case#: PFI2020-00148
Date: 4/21/2020 Address/Parcel: SEG 2395
Pay Method: CreditCard Project Name: NW Natural
EXPLANATION: Per applicant's request. Refund 80%of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104;; $Amount.
PFI Permit Fee 640-0000-43114 $240.00
TOTAL REFUND: $240.00
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager x' 7 t J
If under$25,000 Department Manager
If under$100,000 City Manager
If over$50,000 Local Contract Review Board
^3 'sue "-rx, _ .. rS.--T..,.. r .... f.. .2 i)Z..o" ` f : fin. .. . .: a.ra>t,.
Case Refund Processed: Date: J /3 2/ By: . ,
I:\Budding\Refunds\RefundRequest.doc x 09/01/2010
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT'ECEIVED
g
" APR 2 7 2020
Request for Permit Action
C TY OF TIGARD
1 C1 A R C) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • ww GINEERING
TO: CITY OF TIGARD 1 fl
Building Division V 0
13125 SW Hall Blvd.,Tigard,OR 97223 f/gyp/ -r
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner Q Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) NW Natural
Mailing Address: 250 SW Taylor St
City/State/Zip: Portland, OR 97204
Phone No.: 503-226-4211 x4461
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
Gi CANCEL/VOID PERMIT APPLICATION.
2 Q NI 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#: PF12020 93135 & PFI2020-00148
Site Address or Parcel #: Various addresses
Project Name:
Subdivision Name: Lot #:
EXPLANATION: NW Natural will not be doing these inspections in Tigard.
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Signature: / ✓/�� Date: 4/24/2020
Print Name: Dan Hacker
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.
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FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date 7/,3 2/ By 40?)
Refund Processed: Dat40/I By Q Invoice Processed: Date By
Permit Canceled: Date haze BvA)O Parcel Tag Added: Date By
1:\Building\Forms\RegPem9tAction_ _051 .doc
IICITY OF TIGARD RECEIPT
I 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TI(;Ai3T7
Project Name: NW Natural Valve Inspections. 3604953
Site Address: /a6�, /Q6
Receipt Number: 435818 - 08/13/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12020-00148 $-240.00
Total: $-240.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 240241 DHOWSE 08/13/2021 $-240.00
Payor: NW Natural
Total Payments: $-240.00
Balance Due: $240.00
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CITY OF TIGARD1111 RECEIPT
ii 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: NW Natural Valve Inspections. 3604953
Site Address: C/
Receipt Number: 429084 - 04/21/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PFI2020-00148 PFI Permit Fee 640-0000-43114 $300.00
Total: $300.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 6290641 PUBLICUSERO 04/21/2020 $300.00
Payor:
Total Payments: $300.00
Balance Due: $0.00
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