PFI2016-00247 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENTV
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 TigardBuildingPerrnits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ,a City Staff
Check(-)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEMS) 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 #: Pfl uko-
Site Address or Parcel#: Sq�
Project Name: C YYI CAS
Subdivision Name: Lot#:
EXPLANATION: Wj A Ad _-
,T A 7 Tz /Zd 0e- S4-) &,ge.6e7V �L
Signature: Date:
Print Name:
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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: Datg/.Z / B
Refund Processed: Date -By ilW Invoice Processed: Date B
Permit Canceled: Date /,? / B Parcel Tag Added: Date B37
I:\Building\Forms\ReqPenyvtAction-09r2314.doc
V RECEIVED
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City of Tigard NOV 0 3 2016
PUBLIC WORKS —ENGINEERING CITY OF TIGARD
,� gNNWG�ENGiNEERING
Public Facility Improvement (PFI) Pejrrut
DESCRIPTION OF WORK(in the right-of-way) TYPE OF WORK
Check one: N Utility Connection
❑ TYPE 1—Franchise Utility Work
❑ Sidewalk/driveway approach Work performed by NWN,PGE
❑ Street improvements and/or utility agency.
Detailed description: Comcast proposes to repair existing underground ❑ TYPE 2-Sidewalk/Driveway/Sewer
conduit within the city of Tigard ROW. Work performed for the purpose of:
• Sidewalk installation or repair.
• Driveway approach installation
Property address/location(s): 12006 SW Garden PI, Portland,OR 97223 and/or repair
S>✓G► �V • Sanitary sewer lateral installation
O V and/or main line tap
❑ TYPE 3—Full scale Development
Applicant: Comcast Work performed with Land use
Address: 11308 SW 68th Parkway approval which includes any of
the following:
City/state: Tigard, OR Zip: 97223 • Subdivisions or Partitions
Phone: (503)596-3819 Email: Scott-Sarber@comcast.com • Street widening
Contact name: Scott Sarber Phone: (503)596-3819 Mainline installation for Sanitary
sewer,Storm sewer,Tigard water
Contractor: NX Utilities and/or Tigard Water Service Area
CCB#: 178798 Expiration: 9/20/2017 SUBMIT COMPLETED APPLICATION TO:
Address: 1947 Claxter Rd NE City of Tigard
City/state: Salem, OR Zip: 97301 Planning/Engineering
503 910-7396 comcastcamas@nxutilities.com 13125 SW Hall Blvd.
Phone: ( ) Email: @
Tigard,OR 97223
Contact name: Sergio Medel Phone:
Tigard,
for"minor work in right-of-way"
only may be emailed to:
Engineer: K&B Technical Soluntions ro ermits .tigard or.Qov
Address: PO BOX 2529
City/state: Clackamas, OR Zip: 97015
Phone: 503-650-6041 Email: Shane-Langley@kbmail.net Case No.: PE12 LO-bD241
Contact name: Shane Langley Application submittal fee:
Additional fees:
Estimated value of work is required(if over$5,000):$ Application accepted:
(within the public right-of-way) By: A-Y— Date: �P
Application reviewed:
Is work related to a LAND-USE DECISION? ElYes W No
By: Date:
If so,please specify (MLP, SDR,SUB, etc.) case #:
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes R No By: Date:
If so,please specify(BUILDING PERMIT)case#: l:\CURPLN\Masters\land Use Applications Rev.07/09/2015
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 does not violate any deed restrictions that may be attached to or imposed upon the subject proge
• 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.
DigBelly 5igneE by Glen N§YI•mY
Glen Williams o� lG� walWms�k'b" lnel"US Glen Williams (For Scott Sarber) 11/3/2016
Date:2018.11.03 10:58:21-07'00'
Applicant/Authorized Agent's signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
Owners 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
Public Facility Improvement(PFI) Permit: DE"I'All-1,A) SUBMITTAL
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.
Engineer's estimate X 5% (less$300.00 submittal fee) (work in the right of way)
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:
There will be no permit fee charged,or assurance required FULL SCALE DEVELOPMENT
for the following types of work: (Subdivisions/Partitions and Street Improvements)
• Sidewalk repair (less than 20 lineal feet)
• Relocate or replace mailbox Design Plans
• Ditch cleaning that does not involve regrading. (6 sets,24x36 or 2204)
• Weephole 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 -40— Ditch —�
Streetlight I ---•—•—•—•—•—•—r—•—
f• e RainDrain
1 ' ; I .,
1
' T��r'S�3'o3r �wer1'iR�"
' q.? I r
I a,,� � Existing House �
Existing
Fy 1 I 21 Driveway
ai I
CI w I � ;^•
�A r I
o,
-E�o .
i I Existing Shop j
t
Powerpole 1 I I d
o
95
—•------7opine-----------
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II Fire Hydrant(FH)
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Scale: 1"=30'
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1 I I
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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 - 503-718-2421 - Page 4 of 4
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54
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FGD scALe+I3v STRUCTURES.
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56' 3.R IS THE CONSTRUCTION
wGq EN C CONTRACTORS RESPONSIBILITY TO R P 1
77' RO CALL FOR LOCATES BEFORE
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-_ DIGGING.
4.EX.CONDUIT- CMME-7575335E