PFI2019-00435 i
TIGARD
City of Tigard
January 28,2020
NW Natural
PO Box 6017
Portland, OR 97228-6017
Re: Permit No. PFJ2019-00435
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 13333 SW 686 Pkwy
Project Name: NW Natural
Job No.: N/A
Refund Method: ® Check#234488 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 scope of work changed and permit no longer
required. Refund 80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
IIlii
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 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: 1/17/2020
220 NW 2"d Ave
Portland, OR 97209 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 427287 Case#: PFI2019-00435
Date: 12/09/2019 Address/Parcel: 13333 SW 68th Pkwy
Pay Method: CreditCard Project Name: NW Natural
EXPLANATION: Per applicant's request as scope of work changed and permit no longer required.
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: SIGN R /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: 9/3/.f By: I .1
I:\Building\Refunds\RefvndRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
III • 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: NW Natural
Site Address:
Receipt Number: 436205 - 09/03/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12019-00435 $-240.00
Total: $-240.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 234488 DHOWSE 09/03/2021 $-240.00
Payor: NW Natural
Total Payments: $-240.00
Balance Due: $240.00
Page 1 of 1
CITY OF TIGARD1114 RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: NW Natural
Site Address:
Df2-(6 (A/4-4--
Receipt Number: 427287 - 12/09/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12019-00435 PFI Permit Fee 640-0000-43114 0 % $300.00 Oet
Total: $300.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 5837354 PUBLICUSERO 1 210 9/2 01 9 $300.00
Payor:
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
VOID
• City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ���/�
!Pig20 Mr
Request for Permit Action
I I G A R D 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 12j Applicant ❑ Contractor ❑ City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) N W N otim.ra.Q
Mailing Address: 270 N W 2„,frwi Ave.
City/State/Zip: Porflavl4 , 0 (L £ 7 2OCJ
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL/VOID PERMIT APPLICATION.
'it) (o REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
�e,`yty�pl ❑ INVOICE FOR FEES DUE (attachcase fee schedule and provide explanation below).
Permit#: pP12i0le1 C0 4? 5
Site Address or Parcel#: S ?)51 ?9
Project Name: N VJ N ottk Y l
Subdivision Name: Lot#:
EXPLANATION: WD{- ktrou Goa, U U of , ( entrvcld' no I
Signature: Date: I Z 110 t I
Print Name: /tjtnes (�hp((/y
_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. 3crt) L7-7 _ G O
4bec / /2/9 i9
FOR OFFICE 1 SE ONLY
Route to Sys Admin: Date B Route to Records: Date '
Refund Processed: Date /j7/ic By ,l�fr Invoice Processed: Date
Permit Canceled: Date fdlidzo 7) I By .1'". Parcel Tag Added: Date By
7:\Building\Forms\RegPermitAction_20518.doc
Agnes Lindor
From: Kirschenman, Shelly <Shelly.Kirschenman@nwnatural.com>
Sent: Tuesday, December 10, 2019 10:47 AM
To: ROW Permits
Cc: Kelley, Brian
Subject: RE: NW Natural ROW Permit Request/ 13333 SW 68th Parkway/WO#3596901
Attachments: Application Tigard 3596901.pdf; Plat 13333.pdf; TCP 320.pdf
Categories: Misc. Correspondence
Caution!This message was sent from outside your organization. Allow sender I Block sender
Hello-
Can we please cancel this permit request as the work changed and we no longer will need a
permit.
Thank you,
Shelly Kirschenman
NW Natural—Permitting Specialist
503.226.4211 x 4347 I smk@nwnatural.com
From: Forge,Jamison
Sent:Thursday, December 5, 2019 9:24 AM
To: 'ROWpermits@tigard-or.gov' <ROWpermits@tigard-or.gov>
Subject: NW Natural ROW Permit Request/13333 SW 68th Parkway/WO#3596901
Please see attached for ROW permit application.Thank you!
Thank you,
Jamison Forge(He/Him/His)
NW Natural—Technical Coordinator
503.226.4211 x4542 I nwnatural.com
1
RECEIVE V / %t: i'e .: r7--
City of Tigard DEC 0 5 2019 PFI#:�419- Od y3�'
ENGINEERING DEPARTMENT CITY OF TIGARD
PLANNING/ENGINEEr:. .
TIGARD Public Facilities Improvement (PFI) Permit
PROJECT INFORMATION TYPE OF WORK
Project name: WO#3596901 I— TYPE 1—Franchise Utility Work
Brief description of project: Locate and operate curb valve to remediate performed by NWN,PGE, or utility
agency
minor leak.Valve may be paved over. Standard t-cut required if paved. 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
13333 SW 68th Parkwaymain line tap
Location (address if available):
I TYPE 3—Full Scale Development Work
S og_ . c..9. performed with land use approval which
includes any of the following:
• Subdivisions or Partitions
APPLICANT INFORMATION • Street widening
Name: Jamison Forge NW Natural • Mainline installation for sanitary sewer,
storm sewer, 'Tigard water, and Tigard
Mailing address: 220 NW 2nd Ave water service area
City/State: Portland OR zip: 97209 I- TYPE 4—Small Cell Technology
Phone:
503-226 4211 x4542 I— TYPE 5—Tigard Triangle
Email: Jamison.Forge@NWNatural.com Phone: 503-226-4211 x4542 NOTE: Type 1 and 2 applications may be
Contact name: Jordan Lilly emailed to rowpermits@tigard-or.gov.
Phone: 503-226-4211 x4543 Email: W JYL@NNatural.com
CONTRACTOR INFORMATION E Same as applicant
Name: 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? E Yes -No Case number:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.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.
Forge, Jamison L = " ""`—" Jamison Forge 12/05/2019
Applicant's or authorized agent's signature Print name Date
Property owner's signature (if required) Print name Date •
Case No:) /aaq- K' Permit fee: 300•DO Received by: Date: P
Approved by: /1-leilf,e. Date: /2/9/Z019 Notified by: Date: LZf of 19
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 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? I Yes No TYPE 1 AND TYPE 2-Must include a sketch
showing:
Under the wireless facilities standards,is the proposal L Dimensions
considered?(check all that apply): Small Cell Macro (— Street Name
• Site Address
How many install sites are proposed as part of this permit
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
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.)
L Details
• Traffic Sight Distance
L Signing and Striping
L Street Light Plan and Photometric
L Engineers seal/signature
I— Sheet label(project land use name,revision and plan
log block,dates and sheet numbers.)
L Engineer's Construction Estimate
Additional Submittals
(per land use conditions,if applicable)
• Traffic Report
I— Storm water Drainage Calculations
L Geotechnical Report
L Preliminary Access Report(Sight Distance)
L Proposed Plat
L Pathway Design
L Water Provider Approval
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 3 of 4
9 sw "y" s 1
Edge of Pavement
�— Ditch
Streetlight _ — —•—•—•—•—•— —r—•—
i
i T-1/1opose^d•SewerTine"
im ! Existing House I
Al 1 Existing 1
Driveway
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1 Existing Shop I
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iO I Fire Hydrant(FH)
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iI Scale: -I"=30'
I
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i I
i
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 • wwwtigard-orgov • 503-718-2421 • Page 4 of 4
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NW Natural PLAT: 1-044-022 COUNTY: WASHINGTON C' 12/05/19 07:50
(503)226-4211 TOWNSHIP: T02S RANGE: RO1W SECTION: 1SE SCALE: 1 IN=110 FT J USER ID:pa
Page 84 2011 Edition
Stationary Lane Closure with Flagging . Diagram 320
Diagram 320 covers total closure of one lane of a two-lane, two-way
roadway. See the detail inset for the layout if using a single flagger to control
both directions of traffic on low 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 ADT.
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
maybe pl
aced warning and Flagger Ahead symbol signs p aced 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. The"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.
Chapter 5 December 2011
2011 Edition Page 85
Stationary Lane Closure with Flagging Diagram 320
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Sign Spacing and Buffer Lengths(feet) /m of
Posted Spacing Between Signs Buffer Q Lu O 2 C
Speed A B C Space-t V \,..zO 0 a O
20 50 I ��
25 100 100 100 75
30 100
40 125
350 350 350 150 :2 0 O 5
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45 180
50 500 500 500 210
55 250
December 2011 Chapter 5