PFI2020-00118 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
111 s COMMUNITY DEVELOPMENT Permit#: PFI2020-00118
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 04/01/2020
TIGARD 9 Parcel: SEG2363
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: PGE
Project Description: SEG 2363/1550 SW 72nd Ave. Bond Street light and flood light.
Class of Work: FEES
Type 1 -Utilities(gas,electric, data) Description Date Amount
PFI Permit Fee 03/30/2020 $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.tigard-oroov to schedule inspections online.
Contractor:
PHONE:
Applicant:
JEREMY SAMPSON
2213 SW 153RD AVE
BEAVERON, OR 97003
PHONE: 5035154083
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.
PermSignature:
a pp I
Signature: �,/u/��
Issued By: A-70 (/lam
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PFI2020-00118
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 applicants 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
971-228-9269, 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
City of Tigard RECEIVED
C ENGINEERING DEPARTMENT LIAR 9,
2Zfl PFI#: 2020-00118
TIGAhI) Public Facilities Irnprovei t (PFI) Permit
PROJECT INFORMATION TYPE OF WORK
Project name: PGE Job # M2856784
8 TYPE 1-Franchise Utility Work
Brief description of project: performed by NWN,PGE, or utility
agency
bond street light and flood light ❑ 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
main line tap
Location (address if available): ❑ TYPE 3-Full Scale Development Work
15500 SW 72nd ave pole 1695 SEG2363 performed with land use approval which
includes any of the following.
• Subdivisions or Partitions
APPLICANT INFORMATION • Street widening
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 4-Small cell Technology
503.612.6093 ❑ TYPE 5-Tigard Triangle
Phone:
Email: preregcoord@pgn.com Phone:
NOTE: Type 1 and 2 applications may be
Sampson
Contact name:
JeremySam .,,,ailed to rowpermitsCatigard-or.gov.
Phone: 503.515.4083 Email: preregcoord@pgn.corn
CONTRACTOR INFORMATION 0 Same as applicant
Name: pge crew CCB Number:
Mailing address: City/State: Zip:
Phone: Email:
ENGINEER INFORMATION
Name:
Mailing address: City/State: Zip:
Phone: Email:
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? Oyes El No Case number:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtiga.rd-ox.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.
Lts.t Z Qet:" Linda Ott for Jeremy Sampson 3.26.20
Applicant's or authorized agent's signature Print name Date
Property owner's signature (if required) Print name Date
STAFF LSE ONLY
Case No:PFI2020-00118 Permit fee: •v() Received by: AL Date: 3/26/20
Approved by: -64 Date: 312&/Z600 Notified by: Date: 3
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 PH 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 PH 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? 0 Yes ❑ 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 0 Macro ❑ Street Name
How many install sites are proposed as part of this permit
O 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 0 Private Property
❑ Cover—Site,Vicinity,Abbreviation,Legend
❑ General NotesWater,Sewer,
If equipment is to be located on private property,describe the etc.)
type&use: ❑ Street(Plan,Profile)
❑ Water,Storm and Sanitary(Plan Profile)
0 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.)
❑ Engineer's 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
O Water Provider Approval
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www:tigard-or.gov • 503-718-2421 • Page 3 of 4
f' S 11' .. y •• S t
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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 • wwwaigard-or.gov • 503-718-2421 • Page 4 of 4
c2112D 1695
M2856784
15500 SW 72ND AVE,TIGARD,OR
4 BOND STREET LIGHT AND FLOOD LIGHT
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Diversion into a Continuous Left Turn Lane Diagram 430
ROAD
WORK �.
AHEAD
4yt
CENTER
LANE
CLOSED
AHEAD
A
Provide spotter(s)to
• assist pedestrian traffic
01 safely around work area,
when a safe detour route
Is not available.
L/2 0
O
•
Buffer
V
Protection Vehicle
w/TMA(both Optional)
See Chapter 4
• .11111
• Buffer
• •
• 0
0 L/2
• 0
0
A1 I •
0
U2 0 A
0
o411101°
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yROAD
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www.invarion.com
Diversion into a Continuous Left Turn Lane Diagram 430
Diagram 430 shows work in the travel lane(s) next to a continuous two-way
left turn lane with one direction of traffic diverted into the continuous two-way
left turn lane.
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. When two or more travel lanes are reduced to a single lane before the
diversion, each lane shall be closed separately. Layout traffic control
according to ODOT Standard Drawing TM 852 for 5-lane sections.
4. A shifting taper (L/2) may be added in the diverted traffic direction
across the continuous two-way left turn lane (as shown). This option is
recommended when the speed is 45 mph or greater.
Sign Spacing and Buffer Lengths (feet)
Posted Spacing Between Signs Buffer
Speed A B C Space ERRATA:
20 50
25 100 100 100 75 Supplement Table
30 100
35 350 350 350 125 Updated: February 12,
40 150 2016
45 180 By:ODOT Traffic-Raodway
50 500 500 500 210 Section
55 250
Signs Spacing and Buffer Lengths (feet) Supplement
Posted Spacing Between Signs "Buffer"
Speed A B C Space
60 285
65 700 700 700 325
70 365
www.invarion.com
Bicycle Accomodation Diagram 5-6
NOTES:
- Bicycles on Roadway (CW11-1) sign should not
interrupt standard sequences. For example:
BE PREPARED TO STOP/Flagger Symbol
LANE CLOSED AHEAD/Lane Ends
Work Symbol
- Bicycles on Roadway sign typically follows ROAD
Area WORK AHEAD sign and used as general warning.
Tir
A
I A
I
t ON
ROADWAY
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WORK
AHEAD
www.invarion.com
Bicycle Accomodation Diagram 5-6
Bicycle Accommodation Principles:
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 (CW11-1) 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 Spacing and Buffer Lengths (feet)
Posted Spacing Between Signs Buffer
Speed A B C Space
20 50
25 100 100 100 75 ERRATA:
30 100
Supplement Table
35 125
350 350 350
40 150 Updated:February 12,
45 180 2016
B50 500 500 500 210 y.ODOT Traffic-Roadway
Section
55 250
Sign Spacing and Buffer Lengths (feet) Supplement
Posted Spacing Between Signs "Buffer"
Speed A B C Space
60 285
65 700 700 700 325
70 365
i.
11
TIGARD
City of Tigard
March 9, 2021
PGE
10800 SW Avery St
Tualatin, OR 97062
Re: Permit No. PFI2020-00118
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: Street segment SEG2363/1550
Project Name: PGE
Job No.: M2856784
Refund Method: ® Check#238571 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,
"CC,OKA/v`e1"---1
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
;. - 'I City of Tigard
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 forPermit 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 Ornelas
AL
TRANSACTION INFORMATION:
Receipt#: 428861 Case#: PFI2020-00118
Date: 3/30/2020 Address/Parcel: SEG2363/1550
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
PFI Permit Fee 640-000U-43114 S240.00
TOTAL REFUND: $240.00
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager —at.i—�
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: By:
I:\Building\Refunds\RefundRcquest.doc x 09/01/2010
IIICITY OF TIGARD RECEIPT
■ 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: PGE
Site Address: 16 .
Receipt Number: 436252 - 09/04/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12020-00118 $-240.00
Total: $-240.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 238571 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
TICA.tt.L0
Project Name: PGE
Site Address:
61Z/ 6 i til9Z.--
Receipt Number: 428861 - 03/30/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12020-00118 PFI Permit Fee 640-0000-43114 $300.004
Total: $300.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 6225167 PUBLICUSERO 03/30/2020 $300.00
Payor:
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V U
!hi " Request for Permit Action 6/laze Aio
, i; i 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
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 jg Applicant ❑ Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
ffCANCEL/VOID PERMIT APPLICATION. -.j . , /R.• 1(2117-47..1
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#: P 12( - I IS
Site Address or Parcel #: S 2 ?,Le 3 / 1 SSD
Project Name: P Fj ei
Subdivision Name: Lot#:
EXPLANATION: V 019 (AGVI Galen(
IFuK9 'SDTn f-s 1" ,tT u1 6-s tsg-cc.e-6. ,
Signature: V 'ke — Date: 5/5/2D
Print Name: VVV Ainef LAkit&r
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. 3av _Z y() _ 6d
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date 9 of Z j By
Refund Processed: Date f/.rI Bk0/0 Invoice Processed: Date By
Permit Canceled: Date / )/2e0 14 Parcel Tag Added: Date By
I:\Building\Forms\RegPemutActiun_555222bbb51&doc
Agnes Lindor
From: Denise Choin <denise.choin@pgn.com>
Sent: Monday, May 4, 2020 9:31 AM
To: ROW Permits
Subject: Canceled job
Caution!This message was sent from outside your organization. Allow sender I Block sender
Hello,
PGE Job M2856784, 15500 SW 72ND AVE, was issued your permit PFI2020-00118. 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
E Administrative Assistant, Pre-Requisite Line Dept•503-612-2851
� 10800 SW Avery St.,Tualatin, OR 97062
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