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PFI2021-00350 �.._� City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V Request for Permit Action r I i_i A is 11 13125 SW Hall Blvd. • Tigard,Oregon 97223 • 503-718-2439 • www.dgard-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 Q City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): © 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#: PFI2021-00350 Site Address or Parcel #: 16430 SW 93rd Ave Project Name: Silva Sidewalk Subdivision Name: Lot#: EXPLANATION: No longer going to be doing this work. Signature: / p0ti( (7i�1/vt?.GU Date: 3/7/2022 Print Name: Agnesn 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. FOR OFFICE USE ONLY Route to Sys Admin: Date 31-1 -it By '' Route to Records: Date By Refund Processed: Date By Invoice Processed: Date By Permit Canceled: Date y,rztrL By l Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_120518.doc City of Tigard PFI�$: PFI2021-00350 �� ENGINEERING DEPARTMENT TIGARD Public Facilities Improvement (PFI) Permit PROJECT INFORMATION'I N �/ ] / TYPE OF WORK Project name: CJ I I t/a C I�`�a I K 1 1 l ❑ TYPE 1—Franchise Utility Work Brief description of project: d y)/a r 9( ►irj l)r performed by NWN,PGE, or utility // /agency OCUSYS � de (,{ a l K Am7))/l F y TYPE 2—ROW Sidewalk/Driveway/Sewer V i! Ck1'IeWC Add 11,/1 Work performed for the purpose of: 1� U l `� ( l • Sidewalk installation or repair I • Driveway approach installation and repair SITE INFORMATION • Sanitary sewer lateral installation and ) )1t/ (} t t CPO) � ) A /e main line tap Location (address if a ble : i�w v+ V `� ❑ TYPE 3—Full Scale Development Work Ric—V.1 a\ 1O CV Cr!22 LI performed with land use approval which includes any of the following • Subdivisions or Partitions APPLICAvNT INFORMATION t /y ��y� �{��y • Street widening Name, 1-()r��'-\O S \\l n A' \i0 �l u `J • strMainline installation for sanitary sewer, ` 7 J storm sewer, Tigard water, and Tigard Mailing address: I.6�`3C) C V q3r d A v ' / water service area City/State: PCD�A \CA- � Zip: C � Z2 L ❑ TYPE4—Small Cell Technology G`-7 { - ^L Qr g- ,^(� ❑ TYPE 5—Tigard Triangle Phone: ` ) - L �,�y�� t� mom, k . COv� Email: "l 1.1 Z.0 10 (`Phone: en' I - 2Ce23—t NOTE: Type 1 and 2 applications may be J\ 1\ c rY+ r(-- 0\ emailed to rowpermits(n.tigard-or.gov. Contact name: /-f VJ ��\vt `7 ( �j� Phone: Cfl 1- 1 " g�O, Email: k N62 MkcDc9CI. ZjS �. J (I CCfl< CONTRACTOR INFORMATION ❑ Same as applicant Name: N A CCB Number: Mailing address: City/State: Zip: Phone: Email: ENGINEER INFORMATION Name: Mailing address: M 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? 0 Yes 0 No Case number: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 1 of4 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. C;(1/27/20Z t Applicant's or authorized-agent's signature Print name Date 1b0- US` tO a _ /Ob ©S o U c� O' 22-z0 Property owner's signature (if ruired) Print name Date STAFF Se ONLY Case No: PFI2021-00350 Permit fee: S9 Received by: NT Date: 9/22/21 Approved by: '�011417 Date: $/22j2dZ/ Notified by: P(k— Date:el I Iv2► City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-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 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? 0 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 ❑ 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 0 Cover—Site,Vicinity,Abbreviation,Legend If equipment is to be located on private property,describe the ❑ 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 O 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) O 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 • wwwtigard-or.gov • 503-718-2421 • Page 3 of 4 9 sw "y " sr. Edge of Pavement .—• •Ditch •,-- •._• • `Streetlight ( ,•.—r ® r 1 � o � .I tl N Existing House �: 1 Existing 1 � as • Driveway Si 01 I 1 �. l _ I 1 0.I ` : I Si oa 1 I 1 1 \ Existing Shop 1 .. •. -..\ Powerpole I I Im • • I • I o I Fire Hydrant(FH) I I Scale: 'I"=30' i I I I 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 • www.tigard-or.gov • 503-718-2421 • Page 4 of 4 • ' � �� r ; r r , yt1 h ' • i ' as • y \ r ,. • . fir 4 ty • !r•• a r V� • - J wry, I • ., y- �, .'�c i �' Ci . _ • �.�, .a.. .,o ',y' N,,' ft�S, - ��.,# � s , 1 -. y `'Y- }'o,' yak ; yr}'t •"fi r `t�t^�' A. _-.. _ w. l .gfy�; +A. ^. , '' • ... -- `T ,MY } y TIa 5 i � `,Ate - f _ ,',t. 2t:'',r•''. ; pp� 1 f r r 1fy ' ♦ ° t» '"ti ( tJ W f., - i!K 3.1 *y~••i*, i -+0..1." 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