PFI2022-00120 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V
0
Request for Permit Action
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(✓)one r
FUND OR Name:
INVOICE T : ndividuan
Mailing Address:
City/State/Zip:
one 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 provideexplanation below).
Permit#:
Project Name:
Subdivision Name: Lot#:
EXPLANATION: �U p((�(,( ��/Vj( Cy QI i Vl e r ryy,
Signature: VV Date: �Z
Print Name:
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 of collected.
• Not more than 809/6 of the application or plan review fee when an application is withdrawn or canceled before review effort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.
• ' OFFICE USE ONLY
Route to Sys Admin: Date S 24 ZL I B V J Route to Records: Date 1 13
Refund Processed: Date I By Invoice Processed: Date B
Permit Canceled: Date y 1Z 4Z By Parcel Ta Added: Date B
I:\Building\Forms\RegPemtitAction_120518.doc
q City of Tigard PFI#: 2022-00120
ENGINEERING DEPARTMENT
. Public Facilities Improvement (PFI) Permit
PROJECT INFORMATION
PGE Job # M3163805 TYPE OF WORK
Project name: a TYPE 1—Franchise Utility Work
Brief description of project: Upgrade anchors and down guys performed byNWN,PGE, or utility
agency
on pole #28616, #1501 and #3539 ❑ 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
Location (address if available): main line tap
Full
le
13580 Southwest Roy Rogers Road, Sherwood, OR, USA TYPE3—withla dusevapprov l Work
performed with land use approval which
includes any of the following:
Subdivisions or Partitions
APPLICANT INFORMATION • Street widening
Name: PGE Laurinda Dunn • Mainline installation for sanitary sewer,
storm sewer, Tigard water, and Tigard
Mailing address: 10800 SW Avery St water service area
City/State: Tualatin Zip: 97062 ❑ TYPE4—SmallCellTechnology
Phone:
503-612-2932 ❑ TYPE 5—Tigard Triangle
Email: HVA.preregcoord@pgn.com phone: NOTE: Type ] and 2 applications may be
Contact name: Tyler Knaus emailed to[o ermits(&tigard-oL.=.
Phone: 503-679-8310 Email: tyler.knaus@blackandmcdonald.com
CONTRACTOR INFORMATION ❑ Same as applicant
Name: Custom Lighting Services, LLC dba Black & McDonald CCB Number: 155359
Mailing address: 2102 E McLoughlin Blvd City/State: Vancouver, WA Zip: 98661
Phone: 503-679-8310 Email: HVA.preregcoord@pgn.com
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? ❑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.
paow. Laurinda Dunn 3/16/22
Applicant's or authorized agent's signature Print name Date
Property owners signature (if required) Print name Date
STAFF USE ONLY
Case No: PF12022-00120 Permit fee: Received by: SPU Date: 3/29/2022
Approved by: Date: Notified by: Date:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.figard-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 Pemut Fee.See below for calculations.Minimum of x$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 ONLY • ONLY
TYPE 4: SMALL WIRELESS DETAILED SUBMITTAL
CHECKLIST REQUIREMENTS
Does applicant have a right-of-way license? ❑ Yes ❑ 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): ❑Small Cell ❑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
❑ Cover—Site,Vicinity,Abbreviation,Legend
If equipment is to be located on private property,describe the ❑ General Notes(City,Water,Sewer,etc.)
type&use: ❑ 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 • wwwtigard-or gov • 503-718-2421 • Page 3 of 4
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Cityof Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 0 Page 4 of 4
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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
advance warning and Flagger Ahead symbol signs may be placed 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 September 2016
2011 Edition Pace 85
Stationary Lane Closure with Flagging Diagram 320
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SignSpiacineand Buffer Lengths feet
ns "
Posted 5 cin eetween5i Buffer" f I W
Speed A B e SpaceM \ O O
20 50 ♦ Z M Q 0
25 100 100 100 75 O
30 100
35 350 350 350 150Y¢O
45 180 p O Q
SO 500 500 500 210 ¢ 3 Q
55 250
60 285
65 700 700 700 325
70 365
September 2016 Chapter 5
2011 Edition Page 55
Pedestrian Accommodation, Mid-Block Diagram 5-7
The sidewalk should be closed at the nearest intersection on each side of the
work area when a safe, ADA-compliant path through the work area of is not
available.
_.-_- - 91DEWALK CLOSED
61DEWAlI(CLOSED
AHEAD
or
CAQR4 HERE
CROSS HERE
24x12
Type'W1' 24x18
(Mount on B(II)L) Type'W1"
SIDEWALK
CLOSED
24x12
Type'W1"
(Mount on B(II)LR)
(2 Regd.)
SIDEWAI HOSEDSIDEWALK CLOSED
Or AHEAD
CROSS HERE ~-
GROSSHEW
24x12 24x18
Type,
W1'
(Mourrt on B(II)R) Type"W1
December 2011 Chapter 5
2011 Edition Page 53
Bicycle Accommodation Diagram 5-6
I I
I I
I
I I NOTES:
I I Bicycles on Roadway(CW11-1)sign should not
I interrupt standard sequences. For example:
o BE PREPARED TO STOPIFlagger Symbol
o LANE CLOSED AHEAD/Lane Ends
Work
Symbol
I Bicycles on Roadway sign typically follows ROAD
i
Area WORK AHEAD sign and used as general warning.
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ROAD
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AHEAD
December 2011 Chapter 5
Page 108 2011 Edition
5.5 Multi-Lane Roads
Right Lane Closure, Multi-Lane Non-Freeway Diag. 500
Diagram 500 covers work which closes the right lane of a multi-lane non-
freeway road.
If closing more than one lane on a multi-lane road, provide a minimum
tangent distance of 2L between the end of the first lane closure taper and the
beginning of the second lane closure taper.
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 the posted speed is 40 mph or less, the RIGHT LANE CLOSED
AHEAD signs may be omitted.
4. Placement of signs in a non traversable median or other median that is
not a two-way left turn lane is required for lane closures any time there
is room for a truck to be parked on the left, out of the travel lane.
When there is no room for a truck to be parked on the left an additional
RIGHT LANE CLOSED AHEAD sign should be placed on the right side
and placement of signs in the median is optional.
5. If flagging is needed for work vehicle ingress/egress, use Flagger
Layout Detail (see Inset).
Sian Spacing and Buffer Lengths(feet}
posted Spedng Between Sigm 'Buffer
Speed A B C Space
20 50
25 100 100 100 75
30 100
35 350 350 350 125
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 109
Right Lane Closure, Multi-Lane Non-Freeway Diag. 500
1 4 t t
I �
• Protection Vehicle
• wfrMA(both Optlorah
• See Chapter 4
• i
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&iter
for
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414 t It �,�'
ROAD
• - WORK
AHEAD
September 2016 Chanter 5