PFI2017-00053 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENV 0-71Request for Permit Action q7/'
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • N wxv.tigard-ongov
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:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
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 #: W 2-yn-ocD 5 3
Site Address or Parcel #: �(p 25
Subdivision Name: Lot#:
EXPLANATION: ?!7VMW hoi lfti lyd _ DYy- CDUQ Y e( U vicar
PEI 2O V.)-UD2`l4
Signature: Date: 413 1 11-7
Print Name: a
Refund Policy
1. The city's Community Illevelopment Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 809/o of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to Sys Admin: Date B Route to Records: Date �/ /7 / B
Refund Processed: Date /V B Invoice Processed: Date B
Permit Canceled: Date /7 / B Parcel Ta :added: Date B
1:\Building\l�orms\RegVcrmitAc6on_0 2314.doc
City of Tigard () I tlk.�)
RECEIVED
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PUBLIC WORKS — ENGINEERING -7117 ' MAR 3 0 2017
TIGARD Public Facility Improvement (PFVAAT1jWVANG
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way) 'TYPE I–Franchise Utility Work
Check one: 0 Utilities ❑Sidewalk/driveway approach ❑Streetimprovements performed by NWN, PGE
Cut/Abandon 3/4" W service and/or utility agency.
Detailed description: � �
❑ TYPE 2–Sidewalk/Driveway/Sewer
Work performed for the purpose of:
• Sidewalk installation or repair.
• Driveway approach installation
Property address/location(s): 11455 SW 115th Ave, 285'south of SW and/or repair
Burlcrest Dr. Main is on 15'west side of ROW.Will require one 4'X F hard surface cut. • Sanitary sewer lateral installation
and/or main line tap
Applicant: NW Natural S �� 5 E3 TYPE 3–Full scale Development
l�P Work performed with Land use
Address: 220 NW 2nd Ave approval which includes any of
City/state: Portland OR Zip: 97209 the following
Phone: 503-226-4211 Email: m4m@nwnatural.com • Subdivisions or Partitions
Contact name: Michael Martin Phone: Ext 4331 • Street widening
• Mainline installation for Sanitary
Contractor: sewer, Storm sewer, Tigard water
and/or Tigard Water Service Area
CCB#: Expiration:
Address: SUBMIT COMPLETED APPLICATION TO:
City/state: Zip: City of Tigard
Phone: Email: Planning/Engineering
13125 SW Hall Blvd.
Contact name: Phone: Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: only may be emailed to:
EgmTermits(5), ipard-or.gov
Address:
City/state: Zip:
Phone: Email: Case No.: I"n
F j o20/1_Qo zZrt'3
Contact name: Application submittal fee: $
Additional fees: $
Estimated value of work is required(if over$5,000):$ Application accepted:
(within the public right-of-way) By: 071, Date: 31901j?
Application reviewed:
Is work related to a LAND-USE DECISION? O Yes p No
By: Date:
If so,please specify (MLP, SDR, SUB, etc.) case #:
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes p No By: Date:
If so,please specify(BUILDING PERMIT)case#: l:\ENG\PermitApplimtlom\pfLapplication Rev.12/16/2016
e11 Ll t vrd- W of v(Ilya LA iII(Le it P f I rr, js11+1 W«611(/Ws.
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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,if
required by the city pursuant to TMC 15.041.140.
* With the exception of a utility operating pursuant to a valid franchise with the City of Tigard,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. Franchised
Utilities are not required to obtain the owner's signature on the application
BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT:
• The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject
prope
• 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 any 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.
7A� Michael Martin 03/30/2017
Applicant/Authorized Agent's signature Print name Date
SIGNATURES of each owner of the subject property, if required.
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 FOR STAFFUSE' ONLY
Public Facility Improvement(PFI) Permit:
DETAILED SUBMITTAL
REQUIREMENTS
APPLICATION FEE
Part 1: Required submittal fee$300.00
FRANCHISE UTILITY AND SIDEWALK/
PERMIT FEE DRIVEWAY AND UTILITY
Part 2: All non-water system improvements CONNECTIONS,ETC.
(work in the right of way)
Engineer's estimate X 5% (less$300.00 submittal fee)
Engineer's estimate X 2%Plan Review Sketch
(including information below)
WATER SYSTEM FEE ❑ Dimensions
Part 3: All public water system improvements ❑ Street Name
Engineer's estimate X 12% ❑ Site Address
PFI Permit Fee Exemptions: FULL SCALE DEVELOPMENT
There will be no permit fee charged,or assurance required
(Subdivisions/Partitions and Street Improvements)
for the following types of work:
• Sidewalk repair(less than 20 lineal feet)
• Relocate or replace mailbox Design Plans
• Ditch cleaning that does not involve regrading. (6 sets,24x36 or 22x34)
• Weep hole repair ❑ Cover—Site,Vicinity,Abbreviation,Legend
• Curb repair or replacement(less than 20 lineal feet) ❑ General Notes(City,Water,Sewer,etc.)
• Lawn sprinkler system installation or repair ❑ Street(Plan,Profile)
• Street tree pruning or planting ❑ Water,Storm and Sanitary(Plan Profile)
• Planter strip landscape maintenance ❑ Water Quality Facilities
• Test wells ❑ Grading
❑ Landscaping/Tree Plan
❑ Composite Utility Plan(Electrical,Phone,Gas,
Note. A cash assurance may be required per Storm,Sanitary,Water,Signage,Street Lights,etc)
TMC 15.04.140.(customer deposit) ❑ Details
❑ Traffic Sight Distance
❑ Signing and Striping
❑ Street Light Plan and Photometric
❑ Engineers seal/signature
❑ Sheet label(project land use name,revision and
plan log block,dates and sheet numbers.)
Additional Submittals
(per Land Use conditions)
❑ Traffic Report
❑ Storm water Drainage Calculations
❑ Geotechnical Report
❑ Preliminary Access Report(Sight Distance)
❑ Proposed Plat
❑ Pathway Design(if applicable)
❑ Water Department Approval
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
I Ditch
Streetlight I —•—•—•—•—• —r—•—
• �• Rain Drain
' T—propos d'Se1werTine" �
61 Existing House
I I =1 I Existing 1
1 I :1I Driveway
3� 1
d U�
CI � I 1 jam•
10
(U
a
T,'
"I I I
(71° 1
Existing Shop
Powerpole I
I 95'
I I --------76pertyl.ne-----------
� I
I I Fire Hydrant(FH)
� � I
Scale: 1
� I I
I �
� I I
� � I
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 503-718-2421 • Page 4 of 4
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NW Natural PLAT: 1-042-017 COUNTY:WASHINGTON ___ �`� ��- J+ 03/14/17 07:3
(503)226-4211 TOWNSHIP: T01S RANGE: R01 W SECTION: 34SW SCALE: 1 IN=100 FT LTJ users ID:j1s