PFI2015-00197 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V
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Request for Permit Action
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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
(:heck(✓)one
REFUND OR Name:
INVOICE TO. (Business orindiyidual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
4:�
ANCE ID 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 #: PF12015-00197
Site Address or Parcel #: SEG1806
Project Name: PGE
Subdivision Name: N/A Lot#: N/A
EXPLANATION: Per Engineering,this permit is not required.The work was already covered
under PFI2015-00120.
Date: 12/31/15
Signature:
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• Not more than 809/6 of the application or plan review fee when an application is withdrawn or canceled before review effort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
Route to S s admin: Date B Route to Records: Date
Refund Processed: Date Allig B3 Invoice Processed: Date By
Permit Canceled: Date 411/ / B el Tag.added: Date B�
1:\Building\Forms\Regllemut:\ction_ 9231 .doe
R E C EA V 2__'-D V 0 1
City of Tigard DEC 3 0 2015 r
g PGE WORK ORDER# M 1990473 �y/�40
PUBLIC WORKS ENGINFJW S PI FIGAR6
PLAINING/ENGINEERING
Public Facilitymprovement (PFI) Permit
DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL
Check one: 8 Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS
Detailed description: OH-UG Conversion of SW 97th 8 Minor work in right-of-way
(sidewalk repair,curb cut,street
opening,etc.)requires:
•Application form,completed
and signed
•Submit one(1)copy of scaled sketch
Property address/locadon(s): ABT 14325 SW 97th of the proposed work to be done
SE9 /Q��� •Submit one(1)copy of traffic
C� control plan
—OR—
Tod Shattuck/Tsahai Anderson ❑ Substantial project work requires
OR—
Applicant's name: above items and professional
Address: 10800 SW Avery Street engineered plans for:
Tualatin, OR 97062 •Street widening
City/state: Zip: •Subdivision infrastructure
Phone: 503-672-5466 Email: TBDSupportAvery@pgn.com •Main utility line extension:
Storm Drain,Sanitary—Tigard
Water—Tigard Water Service
Contractor's name: TBD 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.
James Stormo - Pinaccle Engineering Tigard,OR 97223
Engineer's name: g g
17757 Kelol Rd Applications for"minor work in right-of-way"
Address: only may be emailed to:
City/state: Lake Oswego OR Zip: ru=ermits .tigard-or.Qov
Phone: Email: Jamesstormo@comcast.net
Case No.: / ,r1QC 7 6-
Estimated value of work (within the public right-of-way): $
Application submittal fee:
Is work related to a LAND-USE DECISION? ❑ Yes p No Application accepted:
If so,please specify (MLP, SDR,SUB, etc.) case #: By: L—R Date: �' 1
Is work related to a BUILDING PERMIT? ❑ Yes ❑■ No Applica Date:' n viewed:
C-i�
If so,please specify(BUILDING PERMIT)case#: By:
Applicant notified:
By: /_ Date:
I:\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
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 APPLICANTS) SHALL CERTIFY THAT:
• The above reQuest dos not violate any deed restrictions that may be attached to or imposed upon the subject�t pro ert
• 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.
D'gi aly signed by TSANAI ANDERSON
TSAHAI ANDERSON Da yl•TSAMNANDERSON®PGNCAM,evUS Tsahai Anderson 12/30/15
Dale:2015.12.30 12:55:02-08ar
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 • www.tigard-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
SAMPLE SKETCH:
Edge of Pavement
I -dQ— Ditch �►
Streetlight I — —•-----•—•— —C—•—
+ e Raaf Drafit
4 :.T--
r 1
� I
T--ro'p'os d�Selnn►erTi'ne"
� I 1
Existing House
I I Existin
,. 21
1 Driveway
C 1 � I 1 •
a!
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o
a
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Existing Shop �
. = 1
J
L
Powerpole
2
I I a 95' 1
y ------'FiopertyLine-------L_
II Fire Hydrant(FH)
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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 • www.tigard-or.gov 0 503-718-2421 • Page 4 of 4
660-PGE SNITCH VAULT A 1 5 701 7 PL-2933 COMMERCIAL LEGEND
1.a. Nor :
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M�L[rwEEN PROVIDED 6 INSTALLED BY CUSTOMER
4'ro WITH 1T'BRAC/3:T5, I-U2 OO F-TS-T
FL 7903a LIGHTNING ARRESTER
11 R3TA11509 V A 2 AL-DB Q FAULT INDICATOR
• `
,2 PD 505 3"TO /=i•� L Ns uL CUTOUT
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029 L MONOED 6 IWTM BY CUSTOMER
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PO 506 a TEM YES COMMENT
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r 165' nAnw ,
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12 IKT PRIMARY Lw05CVE
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FRONTIER TO PULL
D.N.0 A 25 67961 ` "°' ' E�9AHY
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�-- 67961 00012 CONSTRUCTION NOTES: CALOEv
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PD 509 I 1998-20 Fo..l.,nHal.cower.Y•Lus•.o,Aw
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a LIGHTNING ARRESTER 1-142
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PGE ..CONSTRUCTION DRAWING B�! AS-BUILT VERIFICATION 8 NESC VIOLATIONS CORRECTED
SW M T A 2 5 3 2 017 hl.6�^.^I a^allo rcpre a ns FIELD Cm^ry —
7• d Fames: Daft:
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I. O 1 998-30 a7Tt aD Ned TaF RRId mErsm,e9loD RAa R.
3 OB SITE n•.a sle• zv t—°pe° AN-6 CD SDPMfNG REVIEW: ASLWILT BY DESIGNER:
,j. Q Q j TY�ei1 CONTACT SERVICE COORDINATOR 0•n 12,241075 SGVE: 1-40' ACC^^^r'7170001 AwO:=0004545 ND MMM73
O I8G7L1D 31 O 1D yr o AOAMAMY OH-UG CONVERSION
Sw so .R N _ ~ M„ c.cl• 1 9640640 503-73r s.w sow-+as+RlRtsM+Ml /\ Trw-13337 X17.22
QP•��8�°Oo / 3 3 'L�Mv«n c..•• o T•Im/mw TTE!471 : CALL all BEFORE YOU DIG PG All 143
OREGON IAw REOUMES YW TO FOLLOW RULES ADOPTED All N325 SW 97TH
JpI ® THINK N THE OREGON UTIMY NOIIFKATION CENTER DESCRIrtIOH
000000 Off• SW MU OCK • THOSE RULES ARE SET FORTH IN OAR 952-0040010 OH-UG CONVERSION OF SW 97TH
a V ^�^� "'�^' SAFETY MN H 95]-004 YOU MAY OBTAIN COPIES OF C Crx)N(s) wont wnH ENEFT
R O..�^ D.J R.^R Hr6 FIRST! ranFKAT1oN CENIERG ADMINISTRATION 0 (SO 2] 1991) VEnorL WASHINGTON CI1-118 M7936517 1
L Q C= TO REQUEST UTILTY LOCATES CALL THE OREGON R TODN O 72 NE L6 LANE Ry
T•LM Ur 1'raeY aW Dr UTILRY NOTIFICATION CENTER 811 AT(EAST 7RIt x6N1'x TOO SHATTUCK 67T-5166 LANE WHITNEY
NTTY 2 BUSINESS DAYS IMOR TO EXCAVATION C-R hdMt fxw AF S n• 0 POR7AgD GENERAL ELECTRIC CO.-ALL RIGEITS RESERVED
2011 Edition Page 85
Stationary Lane Closure with Flagging Diagram 320
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December 2011 Chapter 5