PFI2014-00122 F44 City of Tigard ` COMMUNITY DEVELOPMENT DEPARTMENT \/ o 1 D
Request Permit Action V /�//��y
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • wwwAi ar�gov
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.dgard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) AJW &JQ-fwz2
Mailing Address: 2 Z-d 111/VV 2 nd AV
City/State/Zip: LAI-/fid c►'] Z0
Phone No.:
PLEASE TAKE ACTION FOR THE ITEMS) 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).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: �-f I ZO/ —Q Q l 2.Z
Site Address or Parcel#: I-cam 1 9 5 &VV 4 fg--f IJ }-ye-
Project Name: L4i 11 4TC-S V-or
Subdivision Name: Lot#:
EXPLANATION: �P�YYt 1�' C►'�Gt P- i ✓) C�Vr4✓' IP) �cC,Q -�D
Signature: Date: 2- J
Print Name: lel U
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80'.of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80N of the land use application fee for issued pem�its.
d) not more than 8(ro of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80"o of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Paver in the same method in Ni hich pavmcnt was received. Please allow 2-4 weeks for processing refunds.
FOR OFFICE I SE ONIX
Rte to Sys Admin: Date Bf Rte t Admin: Datef/ / B
Refund Processed: Date /(/ B Invoice Processed: Date B
Permit Canceled: Date / B Parcel Tag ridded: Date B
Receipt# Date Method Amount$
1:\Building\Pomts\RegPemvtAetion.doc Rev 05/25/2012
RECEIVED
City of Tigard � DEC 01 2014
PUBLIC WORKS—ENGINEERING CITY OF TIGARD
Public Facility Improvement (PFI) Permit,'ENGINEERING
DESCRIPTION OF WORK(in the tight-of-way) REQUIRED SUBMITTAL
Check one: ® Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS
Detailed description: Install short side service,coming of SW Sattler Rd. 8 Minor work in right-of-way
(sidewalk repair,curb cut,street
Main on the 9' in ROW. Possible street cut. opening,etc.)requires:
�r� ^ , � •Application form,completed
c7G� LV✓ and signed
•Submit one(1)copy of scaled sketch
Property address/location(s): 15195 SW 98th Av of the proposed work to be done
•Submit one(1)copy of traffic
WR# 3426664 control plan
—OR—
ura
NW Natural/Judy Doblie ❑ Substantial project work requires
Applicant's name: Y above items and professional
Address: 220 NW 2nd Av engineered plans for:
Portland OR 97209 97209 •Street widening
Ci /state: Zip: •Subdivision infrastructure
Phone: 503-226-4211X4428 Email: nwnpermits@nwnatural.com •Main utility line extension:
- Storm Drain,Sanitary—Tigard
Lo Clark/Wanda Taylor - Water-Tigard Water Service
Contractors name: Y Y Area(includes Durham,King City
CCB#: 52281 Expiration: and a portion of unincorporated
Address:
PO Box 1369 Washington County)
City/state: Zips
Tualatin OR 97062 DELIVER APPLICATION TO:
503-783-1171 wandat to clark.com City of Tigard
Phone: email: @ Y Planning/Engineering
13125 SW Hall Blvd.
Andrew Young Engineer's name: 9 Tigard,OR 97223
Applications for"minor work in right-of-way"
Address: Same only may be emailed to:
City/state: Zip: rermits •gard-or.Qov
Phone: 360-281-6169 Email: afy@nwnatural.eom
• -STAFF USE •
NLY
Case No.: PTr`��� � 1 ZZ
Estimated value of work (within the public right-of-way): $
Application submittal fee:
Is work related to a LAND-USE DECISION? ❑ Yes ❑ No Application accepted:
If so,please specify (MLP,SDR,SUB, etc.) case#: By: �— Date: t
Is work related to a BUILDING PERMIT? ❑ Yes ❑ No Application reviewed:
If so,please specify(BUILDING PERMIT)case#: By: Date:
Applicant notified:
By: Date:
O A! L\CURPLN\Masten\Land Use Applications Rev.07/16/2014
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 1 of 4
I
APPLICANTS
NOTE: Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for work.
*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 owners)must sign this application in the space provided or submit a written
authorization with this application.
BY SIGNING BELOW,THE APPLICANTS) SHALL CERTIFY THAT:
• The above request does not violate any deed restrictions that may be attached to or imposed upon the subject properly.
• If the application is granted,the applicant will exercise the rights granted in accordance with the terms and subject to all the
conditions and limitations of the approval
• All of the above statements and the statements in the plot plan,attachments,and exhibits transmitted herewith,are true;and
the applicants so acknowledge that any permit issued,based on this application,may be revoked if it is found that any such
statements are false.
• The applicant has read the entire contents of the application,including the policies and criteria,and understands the
requirements for approving or denying the application.
SIGNATURES of each owner of the subject property required.
Digitallysigned Judy Do
1JuyDblr,o=NW Natural,ou,
—il=jkd@nwna1ural.om,t=US Judy D O b l i Q
11/24/2014
Date:2014.11.24 14:41:22-08'00'
Applicant/Authorized Agent's signature Print name Date
Owner's signature Print name Date
Owners signature Print name Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2421 • Page 2 of 4
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Page 84 2011 Edition
Stationary Lane Closure wuth,,Flagging'
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 December 2011
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