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PFI2015-00193 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V Request for Permit Action iz/z1rs 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 TigardBuildingPertnits@tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): CANCEL VOID PERMIT APPLICATION. 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#: PFI2015-00193 Site Address or Parcel#: SEG1098 Project Name: NW Natural Subdivision Name: N/A Lot#: N/A EXPLANATION: Per Engineering, this permit is not required. The work was already covered under PFI2015-00076. Date: 12/22/15 Signature: G� 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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. • ' OFFICE USE ONLY Route to Sys Admin: Date By Route to Records: Date/2;z-_qq ,-5- B Refund Processed: Date N By &W I Invoice Processed: Date B Permit Canceled: Date J 2Y /s B Parcel Ta Added: Date B I:\Building\Forms\RegPemritAction_09231 .doc RECD NE® City 0,f Tigard DEC 18 2015 PUBLIC WORKS — ENGINIEKING CITY Q>=TiGARD GINEERING . a . Public FacilityImprovement (PFI) Permit DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL Check one: 0 Utilities ❑ Sidew—A/driveway approach ❑ Street improvements ELEMENTS Detailed description: relocate approx 25' of 1/2" (p) service ErMinor work in right-of-way (sidewalk repair,curb cut,street to make way for new subdivision/street cut/hole hog opening,etc.)requires: WR#3457567 •Application form,completed and signed •Submit one(1)copy of scaled sketch Property address/location(s): 12520 SW Walnut St of the proposed work to be done •Submit one(1)copy of traffic control plan —OR— NW Natural-Lorene Nichols ❑ Substantial project work requires Applicant's name: above items and professional Address: 220 NW 2nd Ave engineered plans for: Portland OR 97209 •Street widening Cir}/state: Zip: •Subdivision infrastructure Phone: 503-2264211 x4372 Email: eln@nwnatural.eom -;Main utility line extension: Storm Drain,Sanitary-Tigard Water-Tigard Water Service Contractors name: n/a .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. Engineers name: n/a Tigard,OR 97223 Applications for"minor work in right-of-way" Address: only may be emailed to: City/state: Zip: rownermits((�ti�•ar�d-or�ov Phone: Email: Calc No.: Estimated value of work (within the public right-of-way): Application submittal fee: Is work related to a LAND-USE DECISION? ❑ Yes 8 No Application accepted: If so,please specify, (MLP, SDR,SUB, etc.) case #: By: 4­4� Date: L2h � Is work related to a BUILDING PERMIT? ❑ Yes © No Application r ewed: By: Date: If so,please specify(BUILDING PERMIT case#: ✓��� t 1��a� d 1� Applicant notified: !Gtcilod/ -'-'t JQ 14 - Odo By: k� Date: fl�~ t:\CURPLN\Mastan\Land Use Applications Rev.07/16/2014 annual Cityof Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 wwwtigard-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 dCCd restrictions that may be attached to or imposed upon the subject pmpa;. • 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. SIG URES of zuh owner of the subject property required. Lorene Nichols 12/17/15 pplicant/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 • www.tigard-or.gov 503-718-2421 • Page 2 of 4 CoNM Wit� 35756 � A N u T 7503 -),Dq- q?53 r �� #,2745 L I I N G r a ogso it ^ a ,� :r o - — - s•(vv� rae�1 z N - - - - t -2-�Prca - - - - - --r(Pyos C I a �� 12370 5? 2'(P)'081JT •: y�j' N to o F P E p� c� #12770 w (03) o y • s � �D 18 D , / a 1 • ao ;� • �� l— P #12780 R aom? OwN�R Q 5�� ,4 �,z , , ( �' (03) 2 17 j r N . C w 13 5 4C. #,2790 of 3 \=_ 2826 /u n r^ f_V R N �y ytQ /�Q ` ry #112�8W a - " 1 D I I I � .� 4 112848 Q 0} 630) 2 OLSON WOODS �I I^ ��� +r, w 1 cAs - 1 r�P Q 3 .W. BLUE ! r ` 4- LM_ 112862 2 • I I �— \\ , l ¢�?� 5 IL U a J —(P 012664 3 • .� a! g n N ' 7 BLUE HERON PARK NW Natural PLAT: 1-043-016 COUNTY:WASHINGTON 12/16/16 11:2 (503)226.4211 TOWNSHIP:T02S RANGE: R01W SECTION: 4NE SCALE: 1 IN=80 FT USER IO:rep Page 78 2011 Edition Work on Shoulder Diagram 210 Diagram 210 covers stationary work with work or parked equipment on the shoulder. This diagram does not cover work on a freeway shoulder. See Diagram 710 for Freeway Shoulder work. 1. Vehicles should be parked as far off the roadway as practical. 2. Use truck-mounted flashing warning lights on work and protection vehicles. See Section 4.3—Lights and Lighted Signs for exceptions. 3. For added visibility, truck-mounted arrow boards or PCMS in caution mode may be used. 4. Arrow panels in caution mode are recommended for work on roads with posted speeds of 45 mph or greater and high traffic volumes, greater than 2000 average daily traffic(ADT). 5. Requirements for signing and devices are shown in Table 5-2, below. Table 5-2: Device and Signage Guidelines Proximity to Edge of Traveled Way More than 15 feet or behind Barrier or Less than 15 feet Guardrail One advance warning sign is Advance warning required and two signs are Work in Place signs, devices, and recommended. More than 1 Hour flashing warning Cone taper is required. Cones lights are optional. along the edge of traveled way are optional. Work in Place Advance warning signs and devices are optional. Less than 1 Hour Sign Spacing and Buffer Lengths (feet) Posted S acing Between Signs Buffer Speed A B C Space 20 50 25 100 100 100 75 30 100 35 40 350 350 350 125 150 45 180 50 500 500 500 210 55 250 Chapter 5 December 2011 2011 Edition Page 79 •n. -t�, �ryp•*.. h Y"r"r� " i s rc gw�'^+ i� �� �Hoer• �. } ioS� �wo �� s� � I t (Optional) • i Protection Vehicle w/TMA(both Optional} See Chapter 4 • • Buffer • • • • L/3* • A * Ir ROAD i WORK OR i oM AHEAD MEAD Initial Warning Sign II t *Use as appropriate-see Table 5-2 December 2011 Chapter 5