PFI2016-00070 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0
3� /�
ITIP 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 TigardBuildingPermit tigard-or.gov
FROM: E] owner E] Applicant 13 Contractor City Staff
( 11,Ck ✓ 11,
REFUND OR Name:
INVOICE TO: (Business or individual)
Mailing Address:
City/State/Zip:
Phone No.:
PL ASE 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 OC
-/ERMIT (do not cancel permit).
Permit #: PFI 2.0 { b — OW I 0
Site Address or Parcel#: J`r--6 29 S b
Subdivision Name: L 11 Lot #:
EXPLANATION: S(Ar rf1 CfeOL+P— � 1✓) er f 0-( � d 1 t4A4.
0. 1 101n -- C.o � S �`� t►`—t . C1
Signature: Date: 3 Zq
Print Name: Y
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 paver in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
• ' OFFICE
Route to Sys Admin: Dat I Bc I Route to Records: Date &416 By
Refund Processed: Date /j- Bt' nvoice Processed: I Date B
Permit Canceled: Date ,3 3� / ByParcel Tag added: Date By
1:\Building\I-'orms\Rcq Pcmti to ction_I 1231 .doc
V 1 D REQ
FIVE
City of Tigard MAR 2 8 2016
PUBLIC WORKS — ENGINEERING PGE WORK ORDER# M1939940
_ =' OF TIGAPLI
Public Facility Improvement (PFI) PeP r '`_�!GINEERNG
DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL
Check one: 8 Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS
Detailed description: R Minor work in right-of-way
(sidewalk repair,curb cut,street
Replace 545ft bad order primary cable opening,etc.)requires:
Conduit to be installed by PGE approved contractor •Application form,completed
and signed
•Submit one(1)copy of scaled sketch
Property address/location(s): 10260 SW Hoodview Dr of the proposed work to be done
Sb •Submit one(1)copy of traffic
_I control plan
–OR–
Kath n Vanderzanden for Phil Merriman E] Substantial project work requires
Applicant's name: Kathryn above items and professional
Address: 10800 SW Avery St engineered plans for:
Tualatin, OR 97062 •Street widening
City/state: Zip: •Subdivision infrastructure
Phone: 503-612-6136 Email: T&DSupportAvery@pgn.com •Main utility line extension:
- Storm Drain,Sanitary—Tigard
- Water—Tigard Water Service
Contractor's name: TO be determined 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: Phil Merriman, PGE Service Design Project Mgr Tigard,OR 97223
3700 SW 17th Applications for"minor work in right-of-way"
Address: only may be emailed to:
City/state: Portland, OR Zip: 97202 ro ermits tigard-orgoov
Phone: 503-963-6943 Email: phil.merriman@pgn.com
FOR STAFF USE ONLY
Case No.: I C_-Z 10 1 U 0 0 0 7 0
Estimated value of work (within the public right-of-way): $
Application submittal ee:
Is work related to a LAND-USE DECISION? ❑ Yes p No Application accepted:
If so,please specify (MLP, SDR, SUB,etc.) case#: By: 610 Date: -1/2 C-1
Is work related to a BUILDING PERMIT? ❑ Yes 8 No Application r ewed:
By: Date: � `�► �1
If so,please specify(BUILDING PERMIT)case#:
Applicant notified:
Su. PFJ_2V I U�-�OSB s Date:
rURPLN\Masters\Land Use Applications Rev.07/16/2014
voaLOB
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.
*When the owner and the applicant arc 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 any deed restrictions that may be attached to or imposed upon the subject proper",.
• 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.
y pyiullyx .^ o,—a —d--.Kathr n pN m=—ht Va^d--d--P—Genual
E--a=PGE Kathryn Vanderzanden for Phil Merriman 3/28/16
Vanderzanden D— a�032510aa�e^7� °05
pale 3016 OJ 25 1015.10-01'00'
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
VVL 3 VT-5789: NEEDS POSTLANDCAPE 10324 WL 1 VT-5276. LEGEND
Install: WL 1-3 Span: Install: w.Move..eRNDONF.au+,Fs INeu(t FACARR:
SU39627 CONC.VAULT COVER PADMOUNT TRF 48"x48"x6" y0y ADandnn: (6)6-POSITION BUS SUBMERSIBLE MsuuAoomowu F.clunesaamFrFAcu+rcs
1 P 72 240/120 PM 75KVA NTLB (545')A-PHASE OF JKT!*2AL��RPmme:
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I CONDUIT
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(10')2-RUNS AL 350KCM TX REMOVE VT-5276 AFTER PGE C R E W --------
(10')2.3"
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FIGHT-OF-WAY PERMIT NOTICE: T
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APERMH FROM THE IOCAL IURISOICTION IS RLOUIREO BEEORf ANY - •f
mANSFrnMFR wp WORK IN IHERIGHTOFWAYMAYBEPEIIFORMEO ONLYPGEAPPROVED
CONTRACTORSANOCONTRACTORS WHO HAVE MADE OTHER SPECIAL
mRNSwLVG£ AGREEMENTS WITH PGE WILL BE—OWED TO WORK LINOER PGES PERMIT L Jf Q V
v, THE CONTRACTOR MUST NOTI THE LOCAL EUR1501CIR)N 48 HOURS
BEFOREWOR—MBEGIN.ACOPYOFTHEPERMITMU5T8EONSRE. ■� �� ¢� AICU
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x TIGARD
SWNOODVIEWDR FOC31' ROW 50' ,. x SOPMEAG REVIEW SBULTBYDESIGNER
scAl_ 3/22/2016 1.6011 1070001 0000014628 M1939940
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10260 10200 _ DURHAM-BATTLER 17822
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% 20 ACCOUNTS ��`/L70260 SW HOODVIEW DR,TIGARD,OR
_ PGE I REPL BIO PRIM CABLE-545 FT sNEEr
LAN r
DATE:02/04/2016 1/4 SECTION 2S-1W-11SE WASHINGTON C21.11c RWTM IOF1
_- M'E(5731 ORANN BY
DESCRIPTION:INSTALL MICRO-PAD .R PHIL MERRIMAN 1104.3579 ChmtlAR S-C
A TR 5
Page 84 2011 Edition
€Statiori;*"y_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 December 2011
CD Cn PO
(7 Vt Ut A A W W N N'O O
(DN O N O to O N O O Ma
B y Single Flagger Operation ,,
I for Low Volumes �I (Optional) 4CL
N u+ W N I (ADT<400) ro Boor Bdn I O.
0 0 o Dd ( BE Z3
`—' I PREPARED ONE LANE
A B B C ROAD
o I 1• >• 1• 3• TO STOP r
AHEAD
ca
0 0 0 — '.®.— — ♦— I ROAD
' I WORK
o cWii o (j Kc K B K e K A I--i AHEAD
O O O N I Hobtllon VeNd.
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N W m I _ m smr
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I I A B B S
I——————_ "
Imo'
I_ 1 mile I -n'
r max.
K K KK � •
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Buffer
Protection Vehicle
ROAD . . w/TMA(both Optional)
WORK IT�1■1•� See Chapter 4
AHEAD i
BE 1
ONE
A,°t of PREPARE TO S OPD Two Flagger Operation 3
w CD
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Ofi M