PFI2016-00037 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V ®
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
REFUND OR Name: N/A
INVOICE TO: (Business or Individual)
Mailing Address: N/A
City/State/Zip: N/A
Phone No.: N/A
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).
Permit#: PF12016-00037
Site Address or Parcel#: SEG3604
Project Name: Frontier Communications
Subdivision Name: N/A Lot#: N/A
EXPLANATION: POD accidentally created duplicates of the same permit. The correct permit
issued was P1712016-00041. Please void this one (PFI2016-00037).
Signature: Date: 3/16/16
Print Name: Lina Smith
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 B• Route to Records: Date 7, / . I 13
Refund Processed: Date By qW Invoice Processed: Date B
Permit Canceled: DateB arcel Ta Added: Date B :7d
I:\Building\Forms\RegPermitAction_0 314. oc
V n 1 , D RECEIVED
FEB 2 9 2016
City of Tigard CITY OF TIGARD
■
PUBLIC WORKS —ENGINEERING PLANNING/ENGINEERING
Public Facility Improvement (PFI) Permit
DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL
Check one: ® Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS
Detailed description: A 50' bore across SW 81 st Ave. between 11287 ❑ Minor work in right-of-way
(side%valk repair,curb cut,street
SW 81 st and the customer at 11300 SW 81 st Ave is requested. This opening,etc.)requires:
will place 1.5" conruit and a flower pole. •Application form,completedand signed
-Submit one(1)copy of scaled sketch
Property address/location(s): t of the proposed work to be done
,1 •Submit one(1)copy of traffic
control plan
OR-
Substantial project work requires
Applicant's name: Frontier Communications/Cousineau above items and professional
Address: 4155 SW Cedar Hills Blvd. engineered plans for:
Ci /state: Beaverton Zi 97005 -Street widening
ty P' •Subdivision infrastructure
Phone: 503-643-0371 Email:_joh0.QQU,ineau ftr.com -Main utility line extension:
- Storm Drain,Sanitary—Tigard
- Water—Tigard Water Service
Contractor's name: Sonicom Area(includes Durham,King City
CCB#: 188116 Expiration: 3/24/2016 and a portion of unincorporatedWashington County)
Address: 1275 S Kodiak Circle
City/state: Cornelius Zip: 97113 DELIVER APPLICATION TO:
City of Tigard
Phone:503-710-2972 Email:mattshore(lsonicom.eom Planning/Engineering
13125 SW Hall Blvd.
Engineers name: John Cousineau Tigard,OR 97223
Applications for"minor work in right-of-way"
Address: 4155 SW Cedar Hills Blvd. only may be emailed to:
City/state: Beaverton Zip: 97005 rompermits .tigard-or.gov
Phone: 503-643-0371 Email: john.cousineau.ftr.com
Case No.: P / `201 6 C-3_77-
Estimated value of work (within the public tight-of-way): 3 2.000
Application submittal fee- 30'�2
Is work related to a LAND-USE DECISION? ❑ Yes R No Application accepted:
If so,please specify(NdLP,SDR,SUB,etc.) case#: By: `5 Date: � ry
Is work related to a BUILDING PERMIT? [I Yes ® No Application ewed
If so, leasespecifyUILDING PERNE case#: B
A.ppNeent notified:
By: Date:
I:\Q1RPLM\Masten\land Use Appika m Rm07/1GM14
City of Tigard - 13125 SW Hall Blvd. - Tigard,Oregon 97223 w-,vwtigard-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.
*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. 11te owner(s)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 prop Ju.
• 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.
SIGN _ URES of s,ggh owner of the subject property required.
John Cougineau 02/26/16
Applicant/Authorized Agent's signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or gov 503-718-2421 • Page 2 of 4
DEVELOPMENT ENGINEERING FEES
L 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 • wwwtigard-orgov 503-718-2421 Page3 of 4
SAMPLE SKETCH:
Edge of Pavement
I '4— Ditch
Streetlight •— —•—•—•—•—•— —r—
Drain
l RainFe Tce � a
a
1
I 1 �o 0 1
� I
11--
' T"Irro'p'os �W�rTine" 1
1 I C')� . Existing House �
I ri I Existing 1
(Do Driveway
a� cii I 1
C1 � I � �•
o�
I
L
I Existing Shop
J ,
Powerpole
Property Line
I ( Fire Hydrant(FH)
] � I
i1 I
1 I Scale:
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MINIMUM SKETCH REQUIREMENTS (Put"N/A"if Not Applicable):
North arrow Property lines&dimension Slope of property
Street&street name(s) Existing building,structures Utility&street light poles
Proposed work Existing curb or edge Trees
Existing S/W or of pavement Existing utility locations
D/W apron (sewer,water,storm)
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard - 13125 SW Hall Blvd. - Tigard,Oregon 97223 - ww%vtigard-orgov • 503-718-2421 - Page 4 of 4
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11287
SW 81 St.
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Q Ave ACROSS SW 81 ST AVE 60' WITH
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