PFI2020-00222 V
City of Tigard • COMMUNITY DEVELOPMENT DEPA TTN'T„„
1111 24
Request for Permit Action r ! n
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TIG A It n 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 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):
ig CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: PFI'WV) - 0022-2--
Site Address or Parcel#: S 32-.49
Project Name: CeleChnill L1,1 . k--
Subdivision Name: Lot#:
EXPLANATION: NO IOV IjCY ClOOly) pvoseiA
/✓O / _.. -- ,49-7 I,
Signature: UUUU R,5 Date: (.Q PO I/0
Print Name: y ti{J j ki4
t Refund Policy J
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date 4/7 By In
Refund Processed: Date /✓,41- Invoice Processed: Date By
Permit Canceled: Date Jzjj /7.0 B Parcel Tag Added: Date By
I:\Building\Forms\RegPemvtAction_1 5 doc
RECEIVED 1 0
tVI//2& /0 6
City of Tigard JUN 2 4 2020 pH
#: 2020-00222
i� s ENGINEERING DEPARTMEI IL�N OF TIGARD
I I(i A it I, Public Facilities"Tiff e ent (PFI) Permit
PROJECT INFORMATION
SW ShadyLn - N584226 - N.686669 TYPE OF WORK
Project name: a TYPE t—Franchise Utility Work
Brief description of project: CenturyLink is proposing to performed by NWN,PGF, or utility
agency.
pull new fiber through an existing conduit in City of Tigard p TYPE 2—ROW Sidewalk/Driveway/Sewer
ROW. Work performed for the purpose of.
• Sidewalk installation or repair
• Driveway approach installation and repair
SITE INFORMATION • Sanitary sewer lateral installation and
Location (address if available):
9735 SW SHADY LN, main line tap
O TYPE 3—Full Scale Development 1,\'irk
TIGARD, OR 97223 SEG3249 performed with land use approval which
includes any of the following
• Subdivisions or Partitions
APPLICANT INFORMATION • Street widening
Name: CenturyLink National • Mainline installation for sanitary sewer,
storm sewer, Tigard water, and Tigard
Mailing address: 214 E 24th St water service area
City/State: Vancouver, WA zip: 98663 ci TYPE 4—Small Cell Technology
Phone:
O TYPE5-7igardTriangle
(503)467-6422
Email: Todd.Hurd@CenturyLink.com Phone: (503)467-6422 NOTE: Type 1 and 2 applications may be
Contact name:
Todd Hurd emailcd to rowpermitsii tieard-ot.pov.
Phone: (503)467-6422 Email: Todd.Hurd@CenturyLink.com
CONTRACTOR INFORMATION 0 Same as applicant
Name: North Sky Communications, Inc. CCB Number: 208747
Mailing address: 10860 SW Clutter Rd City/State: Sherwood, OR zip: 97140
Phone: (503) 949-8195 Email, bstavang@northskycomm.com
ENGINEER INFORMATION
Name: K&B Technical Solutions
Mailing address: 6566 SE Lake Rd. Suite F City/State: Milwaukie, OR zip: 97222
Phone: 925-984-3385 Email: matt_oliver@kbmail.net
ADDITIONAL INFORMATION
Estimated value of work is required(if over$5,000):$ N/A (within the public right-of-way)
Is work related to a LAND USE DECISION? 0 Yes 0 No Case number:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www:tigard-orgov • 503-718-2421 • Page 1 of 4
APPLICANTS
NOTE: Person specified as"Applicant"shall be designated"Perrnittee"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.
/eild- - 614C:11tnC/ \ Matt Oliver 6/24/2020
Applicant's or authorized agent's sip)ature Print name Date
Property owner's signature(if required) Print name Date
>T.11'F USE ONLY
Case No: PFI2020-00222 Permit fee: t3604.6/ Received by: AL Date: 6/24/20
Approved by: //€19lL"fs Date: i /z9/2024' Notified by: Date:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-otgov • 503-718-2421 • Page 2 of
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 FOIL STAFF USE ONLY
l YPE 4: SMALL WIRELESS FACILITY TYPE 1—3:DETAILED SUBMITTAL
CHECKLIST REQUIREMENTS
Does applicant have a right-of-way license? ❑Yes 0 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): 0 Small Cell 0 Macro 0 Street Name
How many install sites are proposed as part of this permit ❑ Site ddress
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:
0 Public Right-of-Way ❑Private Property
❑ Cover—Site,Vicinity,Abbreviation,Legend
If equipment is to be located on private property,describe the 0 General Notes (City,Water,Sewer,etc)
type&use: 0 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.)
❑ 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
❑ Water Provider Approval
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigatd-or.gov • 503-718-2421 • Page 3 of 4
Ed-e of Pavement
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an ra n. y i _
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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 • wwwtigard-or.gov • 503-718-2421 • Page 4 of 4
Page 80 2011 Edition
5.3 Two-Lane, Two-Way Roads
Shoulder Work w! Minor Road Encroachment Diag. 300
Use this detail for non-freeway work which extends into a travel lane and
maintains a minimum 10 foot travel lane. If a minimum 10 foot travel lane
cannot be maintained, or when traffic cannot safely pass by in both lanes
simultaneously, use the appropriate lane closure diagrams—for example,
Diagrams 310 through 350.
A lane closure may be appropriate for conditions such as high traffic
volumes, high speeds, and inadequate approach sight distance to the work
space, or heavy equipment adjacent to the travel 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. Cones shall be placed along the entire length of the work space. If a
protection vehicle is used and work is in place one hour or less, the
taper and tangent devices may be omitted.
4. If the speed is 45 mph or higher, volumes exceed 2000 ADT, or there
is limited sight distance, consider placing cones or tubular markers on
centerline.
5. An arrow board in caution mode or truck-mounted PCMS with
"SHOULDER WORK"or other appropriate message may be used for
higher visibility.
Sign Spacing and Buffer Lengths(feet)
Posted Spacing Between Signs "Buffer"
Speed A B C Space
20 50
25 100 100 100 75
30 100
35 125
350 350 350
40 150
45 180
50 500 500 500 210
55 250
60 285
65 700 700 700 325
70 365
Chapter 5 September 2016
2011 Edition Page 81
Shoulder Work w! Minor Road Encroachment Diag. 300
ROAD
WORK •
AHEAD/
•
Initial
Warning A •
Sign
•
•7
•
(Optional) •
• •
rim
• 1
Protection tn
wi TMA(both Optional)
Optional)
See Chapter 4 • Buffer
•
10' •
minimum •
•
A ROAD
NARROWS
(Optional)
B
41
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tV WORK
Initial
Warning
Sign
September 2016 Chapter 5
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PROJECT SCOPE:PULL FIBER THROUGH EXISTING CONDUIT. a (3)
PROJECT LOCATION'9735 SW SHADY LN,TIGARD,OR 97223 caikmam y "7l
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