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PFI2015-00013
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT RECEIVED Request for Permit Action FEB 18 2015 13125 Ski' Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov CIIYUFTIGARD TO: CITY OF TIGARD PLANNING/ENGINEERI Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 V 0 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPerrnits@tigard-or.gov G FROM: ❑ Owner [ Applicant L_ Contractor ❑ City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) ( � I A�G Mailing Address: f O g -;Q1.14,&4eS-t'7+ye rV City/State/Zip: �(JQ ��-�7' ©� 9-70 (j Phone No.: 5 63- 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). ❑ REMOVE/REPLACE CONTRACTOR ON PERMIT(do not cancel permit). T Permit #: 12.01-5- ©OC 13 Site Address or Parcel#: if j 3 5 S w (±J reirj1J,hyr'q Project Name: , Subdivision Name: Lot #: EXPLANATION: Q �C�e y-YZ Signature: P yam,, 1 Date 1� 'via J Print Name: Refund Policy 1. The city's Community Development Director,Building Official or City I ngincer may authorize the refund of: • Any fee which was erroneously paid or collected. • Not more than 801/o of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. ,Q�?y"�•J 2CTAi / • 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. .3,00,vo tv C),C-7) Route to Sys Admin: Date By Route to Records: Date B Refund Processed: Date By Invoice Processed: Date B Permit Canceled: Date B Parcel Tag Added: Date B L\Building\Forms\RcgPcrmitAction_ 9231 .doc z City of Tigard February 26, 2015 Portland General Electric Attn: Kristine Hendrix 10800 SW Avery St. Tualatin, OR 97062 Re: Permit No. PFI2015-00013 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: 11335 SW Greenburg Rd. Project Name: PGE Job No.: N/A Refund Method: ® Check#216596 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 job was cancelled. 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 0 www.tigard-or.gov City of Tigard 040-1 FA-11 Accela Refund Request This form is used for refund requests of land use, development engineering and building permit application fees. Receipts, documentation and the Requestfor 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: Portland General Electric DATE: 1/19/2015 Attn: Kristine Hendrix 10800 SW Avery St. REQUESTED BY: Dianna Howse Tualatin, OR 97062 TRANSACTION INFOR�tiLkTION: Receipt#: 199369 Case#: PFI2015-00013 Date: 2/12/2015 Address/Parcel: 11335 SW Greenburg Rd Pay Method: CreditCard Project Name: PGE EXPLANATION: Per applicant's request as the job was cancelled. Refund 80°o of permit fees. REFUND INFORMATION: .Fee Description From Receipt - _ Revenue Account No.. Refund Example: Building Permit Fee Example: 2300000.43104 -T$Amount PFI Permit Fee 100-0000-4311= $240.00 TOTAL REFUND: $240.00 APPROVALS: SIGN S DATE: If under$5,000 Professional Staff If under$12,500 Division Manager If under$23,500 Department Manager If under$50,000 City Manager If over$50,000 Local Contract Review Board FOR TIDEMARK SYSTEM ADMINISTRATION USE O Case Refund Processed: Date: 02,6 S I B [:\Building\Refunds\RefundRequest.doc x 09/01/2010 Betsy Galicia From: Beth Hagestedt <Beth.Hagestedt@pgn.com> Sent: Monday, February 16, 2015 10:20 AM To: T&DSupportAvery; Betsy Galicia Cc: Timothy Bell Subject: RE: City of Tigard - PUBLIC FACILITY IMPROVEMENT PERMIT APPLICATION - Subject Site: 11335 SW Greenburg Road - PGE Job# M1535191 PFI2015-00013 Please let me know if this does get canceled.O From: T&DSupportAvery Sent: Friday, February 13, 2015 10:33 AM To: Betsy Galicia (BetsyG@tigard-or.gov) Cc: Beth Hagestedt; Timothy Bell Subject: FW: City of Tigard - PUBLIC FACILITY IMPROVEMENT PERMIT APPLICATION - Subject Site: 11335 SW Greenburg Road - PGE Job# M1535191 PFI2015-00013 Aloha Betsy, Please cancel this permit PGE will not be requiring the permit and please cancel the credit card payment. Mahalo, Kristine Hendrixi T&D Support Work Hours 6:00 am to 3:00 pm Portland General Electric 10800 SW Avery St.,Tualatin,OR 97062 W: (503)612-61051 8: (503)612-6150 1 ®T&DSugportAyery0-yCln.com From: Beth Hagestedt Sent: Thursday, February 12, 2015 3:12 PM To: T&DSupportAvery Subject: FW: City of Tigard - PUBLIC FACILITY IMPROVEMENT PERMIT APPLICATION - Subject Site: 11335 SW Greenburg Road - PGE Job# M1535191 PFI2015-00013 Hi, This has been cancelled with the City of Tigard, so please don't pay this permit fee. Thank you O From: Betsy Galicia [mailto:BetsyG@tigard-or.gov] Sent: Thursday, February 12, 2015 9:55 AM To: T&DSupportAvery; ROW Permits Cc: Beth Hagestedt Subject: RE: City of Tigard - PUBLIC FACILITY IMPROVEMENT PERMIT APPLICATION - Subject Site: 11335 SW Greenburg Road - PGE Job# M1535191 PFI2015-00013 Your permit is approved and ready to issue, please pay the$300.00 permit fee. PF12015-00013. Thank you, 1 Betsy Ruef Permit Technician Assistant City of Tigard I Community Development 13125 SW Hall Blvd Tigard, OR 97223 From: Timothy Bell [mai lto:Timothy.Bel l(abpgn.com] On Behalf Of T&DSupportAvery Sent: Wednesday, February 04, 2015 8:38 AM To: ROW Permits Cc: Beth Hagestedt Subject: City of Tigard - PUBLIC FACILITY IMPROVEMENT PERMIT APPLICATION - Subject Site: 11335 SW Greenburg Road - PGE Job# M1535191 Good morning City of Tigard: Attached please find the Public Facility Improvement Permit application,job sketch, and proposed traffic control diagram for the subject site at 11335 SW Greenburg Road. Technical questions regarding the proposed scope of work may be directed to PGE project manager Beth Hagestedt at (503) 672-5601. General questions regarding this permit application package may be directed to me. Upon approval, please remit the permit to the following email address: T&DSupportAvery@pgn.com Thank you for your time. Best regards, Tim Timothy Bell Transmission & Distribution—Project Support Portland General Electric 10800 SW Avery Street Tualatin, Oregon 97062 (503)612-6138 timothy.bell@pen.com /PGE DISCLAIMER: E-mails sent or received by City of Tigard employees are subject to public record laws. If requested, e-mail may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law. E-mails are retained by the City of Tigard in compliance with the Oregon Administrative Rules "City General Records Retention Schedule." 2 RECEIVED C_�- MIS 3kB 1 89(2015 City o f Tigard v PUBLIC WORKS—ENGINEERING CITY OF TIGARD PLANNING/ENGINEERING Public Facility Improvement (PFI) Permit DESCRIPTION OF RK(in the right-of-way) REQUIRED SUBMITTAL Check one: [ Utilities �(S dewalk/driveway approach ❑ Street improvements ELEMENTS Detailed description: �f ac-e 3 0, X Minor work in right-of way \ (sidewalk repair,curb cut,street t ear 41 SS Y 11 o I Cil S ) opening,etc.)requires: 1J J / •Application form,completed and signed Property ., II / � •Submit one(1)copy of scaled sketch 1133 5 S W r�� Uy-C{ of the proposed work to be done : J •Submit one(1)copy of traffic V. a dress/location(s)' a'r r o control plan —OR— Substantial project work requires Applicant's name: r=71 Q es above items and professional Address: 900 S o` +htt) t -E-K engineered plans for: •Street widening i / tate: Tya o► �.•� . So� 6,7 2' S � + (� IZ Zip: Z •Subdivision infrastructure Su t9r 1 U qY) • ►1'I •Main utility line extension: Phone: Email: �J Storm Drain,Sanitary–Tigard t ` e t^� y � ��E Water–Tigard Water Service Contractors name: b y Area(includes Durham,King City CCB#: _ Expiration: and a portion of unincorporated Washington County) Address: City/state: Zip: DELIVER APPLICATION TO: City of Tigard Phone: Email: Planning/Engineering 13125 SW Hall Blvd. Engineer's name: A Tigard,OR 97223 Applications for"minor work in right-of-way" Address: only may be emailed to: City/state: Zip: ro=Lrmits(@,tigard-or.gov Phone: Email: FOR STAFF USE ONLY Case No.: �/e�l�1 S--060/Estimated value of work (within the public right-of--wap): $2.357 O` • �300 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: LJ Date: s Is work related to a BUILDING PERMIT? ❑ Yes No Application reviewed: By:��C� Date: If so,please specify(BUILDING PERMIT)case#: By:,Appli notified: By: — Date: 2 5 I;\CURPLN\Masters\land Use AppIlmdons Rev.07/16/2014 City of Tigard • 13125 SW Hall Blvd. 'Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 1 of 4 Jla -Iaa`l/ -'01� 6:3o6;oopm 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 owner(s)must sign this application in the space provided or submit a written authorization with this application. BY SIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT: • The above request does not violate an;deed restrictions that may be attached to or imposed upon the subject pMp • 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 orrflI the subject property required. "�b'l G I r-1 D 1- Y 13 ELL- Z Lf pp ant/Authorized Agent's signature Print name Date Owners signature Print name Date Owner's signature Print name Date Owners signature Print name Date PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigaid-or.gov 503-718-2421. • Page 2 of 4 DEVELOPMENT ENGINEERING FEES 1. Public Facility Improvement(PFI)Permit: Part 1: Required submittal fee$300.00 Part 2: All non-water system improvements Engineer's estimate X 5%(less$300.00 submittal fee) Engineer's estimate X 2%Plan Review Part 3: All public water system improvements Engineer's estimate X 12% Total Permit Fee=Part 2+Part 3 PFI Permit Fee Exemptions: There will be no permit fee charged,or assurance required for the following types of work: • Sidewalk or driveway repair(less than 20 lineal feet) • Relocate or replace mailbox • Ditch cleaning that does not involve regrading. • Weephole repair • Curb repair or replacement(less than 20 lineal feet) • Lawn sprinkler system installation or repair • Street tree pruning or planting • Planter strip landscape maintenance • Test wells PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2421 Page 3 of 4 2011 Edition Page 10i Diversion into a Continuous Left Turn Lane Diagram 430 ROAD WORK - A AHEAD �r 11h1t � y CENTER LANE CLOSED AHEAD I� A II � Bitter Protection Vehicle w/rMA(both Optionap i See Chapter 4 M. rBuffer — L/2 • U2 A 1 h1 B ROAD . I WORK AHEAD Le December 2011 Chapter 5 � m Laaa1 BL � N`��\g`sR onuRrr sR ,- �� ° r WR CHECKLIST REM YES COMMENT •"' Ipuw,4ER 211 loom s moaw sl 14co E -• `=.,>.:-' /Gf 710401 Vic mucK X PGE m 511Ry t, SW Shfdy Ln LDU78 X - RO ^O � nAtalc FAGGING Do l+ A 75 30 4 Ash IANDSCVE 2 AL-ce ::M Harm GiYMR S, �+i YW'm D*—S. EAI L,• pR `�:z e o75w •6�7 RL2L011 ,°ao 1ERRER '+ >o MOR t w° V� 1RARIC PIAN a0G1( a If>U 1° Y OIlSI@T I<�++ :<.• r�,ri6°0r2R1 6 Gzh+'K� W O2m la SWL a � rt DRy � � 16L16M.510t1 f; + M 1535191 OUT 2461052 v ,�, USIOM9 jll-3wff '� Cl 1-35C,PROGRESS GREENBLJR8 FEED 1R I �& DM KOM D 197= a x' cmALT C 15 tim awl.x a.a T �vrR c"my nli c� DhafOL� -. .�� •wry. _ 1`335 SVG URG I,ArE Toxier LRldtlk lkhool �. rd CALL BTT BEFORE YOU DIG ATTEs� CE 30'(25'14H)GRAY L Mr. OREGON LAW REQUIRES YOU TO FOUOW RULES ADOPTED , �I THINK �'TME oREGOFL LmLm NonFruraN CENTER. °1N' ERGLASS ST}.T POLE#15 mOSE RULES ARE SET FORTH IN OAR is2-OOI-DOID , e 1 Lis Li-x� `\ ,\� R1oi+nln 1{`I' SAFETY lv1D- °ou,b 7 LED LIGHT O 6'ALUM AR THE RULE 952-001-0090.YOU MAY OBTAIN conFs of M1 19 �{ VAC TRUC FLAGGERS,ROLE THE RULES RY CENTER THE OREGON UTILITY ( FIRSTI Non1=LCR7roN CENTER ADMINISTRATION � lso3-292-19a>) TBUTT l J GRD O REQUEST TIIICA LOCATES CALL THE OREGON Know whaYL below. FUSE AT OURCE IF POS IBLE arum NOTIFICATION PR CENTER RIA AT LEAST Cap belare you dig, 2 BUSINESS DAYS PRIOR TO EXUVATION. T 9 / / f f. \.\ aPGE CONSTRUCTION DRAWING r SDPAAENG REVIEW: ASBUILT BY DESIGNER: !i4 i� 2j AS—BUILT VERIFICATION dL NESC VIOLATIONS CORRECTED O. This documnd accurably rej—enti FIELD construe-- ' / - ,•.•rm 010 Fommon: Date: ./� li�t3a aaa GF: Dertc DAR: Ir"a $LAIR: IWA ACCOUNT: 1070001 AWP 10000WSaI OR NJ.M1336/D7 mu REPLACE 30'(25'MH)GRAY FIBERGLASS STLT POLE#15 IPGE� ° `PROGRESS-GREENBURG zI 1xl7 LOCATION 11335 SW GREENBURG RD, TIGARD OESCRR'TION REPLACEXT25N"GRAY FIBERGLASS STLTPOI.E 0I5.67LEDLIGHTOR WALUMARM SUNSET WC�TON fs1 C11-35C wuuc WTM to UNE CREW CFNTFR DESIGN ry "low(SOT) DRAWN BY I0S°NW233THAVE BETH HAGESTEDT a72-Ml BETH HAGESTEDT HILLSSORO.OR 97124 0 PORTLAND GENERAL.ELECTRIC CO.-ALL RIGHTS RESERVED