PFI2017-00231 l �� CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12017-00231
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 10/30/2017
Parcel: SEG954
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Comcast
Project Description: Directional drill from SW Bell Ct going west 28 feet across road placing 2 inch pipe under road with
CATV to service 12545 SW Bell Ct.
Owner: FEES
Description Date Amount
PFI Permit Fee 10/26/2017 $300.00
PHONE: PFI Permit Fee 10/27/2017 $300.00
Contractor:
FISK COMMUNICATIONS CONTRACTING
6307 NE ST. JOHNS RD., STE B
VANCOUVER, WA 98661 1
PHONE: 360-314-4454
FAX: 360-314-4456 �j w A •�/
Applicant:
RANDY SHIELDS
11308 SW 68TH PKWY
TIGARD, OR 97223
PHONE: 888-824-8264
Total $600.00
Please sign below to indicate acceptance of conditions and return a copy with the proposed work schedule along with names and contact
information of responsible parties before beginning work.
Permittee/Applicant
Signature:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12017-00231
Type: Condition Name: Status: Severity:
PFI_Utilities 01 -WORK SITE REQUIREMENTS Applied Notice
Applicant must comply with all applicable provisions of federal and state law, the Tigard Municipal Code, and the terms of
any agreement with the City of Tigard regarding work to be done pursuant to this permit.
PFI_Utilities 02-WORK SITE AREA Applied Notice
The work area and approach roads shall be maintained in a clean condition, free from obstructions and hazards. The
spreading of mud or debris or storage of materials or equipment of any kind upon any public roadway is strictly prohibited
and violation shall be cause for immediate cancellation of the permit. The City may at any time order immediate clean-up
and suspension of work to accomplish clean-up.
PFI_Utilities 03-WORK SITE EROSION CONTROL Applied Notice
Prior to starting work, effective and approved erosion control devices must be installed and maintained meeting the Clean
Water Services and DEQ requirements. The City may at any time order corrective action and suspension of work to
accomplish effective erosion control.
PFI_Utilities 04-WORK SITE REPAIRS Applied Notice
Disturbed landscaped areas shall be restored or replaced. Existing signs, pavement markings, mailboxes, etc. shall be
reinstalled or replaced,with like kind of material. Obtain City approval of restoration work.
PFI_Utilities 05-TRAFFIC CONTROL SPECIFICATIONS Applied Notice
Applicant shall provide traffic control according to the current edition of the"Manual on Uniform Traffic Control Devices
[MUTCD]for Streets and Highways", U.S. Dept. of Transportation, FHWA, current edition,American Traffic Safety Services
Association [ATSSA], and Oregon Temporary Traffic Control Handbook[OTTCH].
PFI_Utilities 06-TRAFFIC CONTROL PLAN Applied Notice
Submit a job specific traffic control plan. A copy of the approved traffic control plan shall be readily available at the work
area. Traffic control devices, flag persons, etc., shall be in place prior to initiation of construction work and shall be
effectively maintained.
PFI_Utilities 07-TRAFFIC CONTROL ROAD CLOSURE Applied Notice
Public roadway shall not be closed to traffic, at any time,without obtaining written approval from the City Engineer. The
applicant is responsible to provide 48 hour advance notice of traffic flow disruptions to affected businesses, residents and
area wide Emergency Services: 503-629-0111 (Tigard Police Dept., Tualatin Fire&Rescue)and to 503-962-8140(Tri-Met)
and 503-431-2345(Tigard School District)and other service providers impacted by such closure.
PFI_Utilities 08-TRAFFIC CONTROL PROPERTY ACCESS Applied Notice
Access to existing properties shall be maintained at all times, including normal delivery service and mail service. Obtain City
approval of any access closures.
PFI_Utilities 09-TRAFFIC CONTROL WORK HOURS Applied Notice
Work is permitted in daylight between the hours of 7:00 a.m. to 7:00 p.m. Mon-Fri unless otherwise authorized by the City.
PFI_Utilities 10-TRAFFIC CONTROL LIMITED WORK HOURS Applied Notice
Hours of construction work on collector and arterial roads will be limited to 9:00 a.m.to 3:00 p.m. unless authorized by the
City Engineer. Work will not be permitted on collector and arterial roads between 3:00 p.m. to 9:00 a.m. unless authorized
by the City Engineer.
PFI_Utilities 11 -TRAFFIC CONTROL MODIFICATION Applied Notice
The City reserves the right to add to or modify traffic control requirements as necessary to effectively control traffic and to
assure public safety.
PFI_Utilities 12-UTILITY NOTIFICATION Applied Notice
Oregon law requires following the rules adopted by the Oregon Utility Notification Center. Said rules are set forth in OAR
952-001-0100 through OAR 952-001-0080. Copies of said rules may be obtained from the Center by calling 503-246-1987.
If you have any question about the rules, contact the Center. NOTE: Damage to utilities shall be corrected at the permit
holder's expense.
PFI_Utilities 13-UTILITY LOCATION CONFLICT Applied Notice
Applicant must verify all existing utilities for both vertical elevation and horizontal location prior to start of work(pothole
before digging if necessary). Should conflicts arise and redesign or relocation of facilities be necessary, it shall be done at
the applicant's expense. Changes must be approved by the City in advance of work.Applicant shall coordinate the work
with affected utility agencies.
PFI_Utilities 14-TEMPORARY PATCH Applied Notice
A temporary hard-surface patch shall be placed on trenches within roadways at the end of each work shift. Obtain advance
approval of patching method. No trench shall be left at any time in an un-safe condition. Applicant is responsible for and is
liable for hazards or damage resulting from the prosecution of the work.
PFI_Utilities 15-REPAIR OF EXISTING FACILITIES Applied Notice
Work under this permit shall include repair of existing facilities (roads, ditches, etc.)as may be necessary, as determined by
the Inspector,to overcome deterioration or damage which occurred in conjunction with the work authorized by the permit.
Corrective work shall be done at the applicant's expense.
PFI_Utilities 16-PRECONSTRUCTION MEETING Applied Notice
Before initiating any construction activity,the applicant shall coordinate with the City's inspector, <Insert Name>at<Insert
Phone#>, to establish a preconstruction meeting.
PFI_Utilities 17-NOTICE TO COMMENCE WORK Applied Notice
The applicant shall notify the City's Inspector twenty-four(24)hours prior to commencing work, prior to any staged
inspection,and after completing work covered by the permit. Call Ken Fisher at 503 816 6146 or Kenny@tigard-or.gov.
PFI_Utilities 18-PERMIT/PLAN ON SITE Applied Notice
A copy of the permit including a Certificate of Insurance, and all attachments, and a copy of the approved construction plan
and all amendments shall be readily available at the work area. All work shall conform to the permit terms, conditions and
provisions and to the City approved permit plans, and approved plan amendments and to the City's standards and
specifications and to these General Conditions. Changes to any of these must be approved by the City, in advance of work
performance.
PFI_Utilities 19-MONUMENT PROTECTION Applied Notice
Existing monuments, property corners, and survey markers shall be protected. Replacement shall be at the permit holder's
expense.
PFI_Utilities 20-EMERGENCY CONTACTS Applied Notice
Provide to the City inspector, in writing,the names and 24 hour emergency telephone number of two(2)persons who have
authority to resolve problems,take corrective action and, in general,will be responsible in case of any emergency. The
applicant shall notify the City Inspector, in writing, of any/all assignment changes.
PFI_Utilities 21 -OTHER Applied Notice
Lina Smith
From: Margarita Vega <fccmargarita@gmail.com>
Sent: Friday, October 27, 2017 11:33 AM
To: ROW Permits
Cc: fccmaegan (fccmaegan@gmail.com)
Subject: Re: ROW Permit Application:12545 SW Bell Ct, 97223
Categories: Misc. Correspondence
Yes, I can do that.
This has been paid!
Thank you,
Margarita Vega
FISK Communications Contracting Inc.
2705 NE 65th Ave
Vancouver, WA 98661
Office: 360-314-4454
fccmar ag rita((�,gmail.com
This email and anv tiles transmitted with it are confidential and intended solely for the use of the individual or entity to which they are addressed.If you have received this email in
error please notiA,the system manager.Please note that any views or opinions presented in this email are solely those of the author and do not necessarily represent those of the
Company.Finally_the recipient should check this email and any attachments for the presence of viruses.The Company accepts no liability for any damage caused by any virus
transmitted by this email.
On Thu, Oct 265 2017 at 4:50 PM, ROW Permits <rowpermitsa tigard-or.gov> wrote:
Hi Margarita,
.Another customer accidentally paid for your permit, and.we're working to issue her a refund. In the
meantime, can you go to the website main to pay for this permit? I re--invoiced the $300, and I can issue
the permit as soon as you finish paying.
Thank you!
City of Tigard
Public Facility Improvement (PFI) Permits
Phone: (503) 718-2421
E-mail: rowperinitsati arm d or.gov
i
RECEIVED
City o f and OCT 17 2017
fTit g
a PUBLIC \\ ()RISS — L-'NGINEERING CITY Oil:TIGARD
:..� ING/y NGINEERING
Public (An--47Permit
'I'YPE OF WORK
DESCRIPTION OF WORK(in the right-of-way) TYPE 1—Franchise Utility\\urk
(.heck one: ❑ Utilities ❑ Sidewalk./driveway approach ❑ Street improvements X performed by N\\,'N, 13Gf-.
Detailed description: Directional drill from the ped, on the west and/or utility agency.
side of SW Bell Ct going west 28'across road placing 2" ❑ TYPE 2-Sidewalk/Driveway,
Work performed for rhe purhuse�,t:
pipe under the road with CATV to service 12545 SW Bell Ct ___ - Sidewalk installation or repair.
Ptopern12545 SVV Bell Ct, 97223 - Driveway approach installation
address/locaac�n(s): _ and/or repair
- Sanitary sewer lateral installation
and/or main line tap
Applicant: Randy Shields for COMCAST CABLE ❑ TYPE 3—Full scale Development
Work performed with Land use
Address: 11308 SW 68th Pkwy approval which includes any of
Cite/state: Tigard, OR /ij,. 97223 the following:
360-301-1962 Rand Shields cable.comcast.com - Subdivisions or Partitions
Phone- Email: Y_ @
Contact name: Y Phone:
Rand Shields 360-301-1962 - Street widening
- Mainline installation for Sanitan•
Fisk Communications Contracting Inc. sewer, Storm sc-,%?cr, 'Tigard water
( r)ntraetclr: 9
ORCCB# 185632 and/or Tigard Water Scrvicc Area
C(.:13#- Eaplraticm: 2/24/2019
Address: 2705 NE 65th Ave SUBMITCOMPLETEDAPPLICATIONTO:
City/state: Vancouver, WA /il,: 98661 City of Tigard
360-314-4454 fccmar arita mail.com Planning/E�rgincering
1 hone:: _ Inlall: _ g @9 - 13125 SW Hall Blvd.
{`()rltact n:tnlc: Margarita Vega photic: 360-314-4454 Tigard,OR 07223
pplic:uio»1s for"minter work in right-of--.%,;n"
only may.be emailed to:
:lciciress:
l:ndress:: rowperinits a egad-or.gov
FOR STAFF USE ONLY
City/state: Zip:
Phone: I�maiL Case No.:��/�Q l'7, O 61
Contact name: Application submittal fee: $—401p, Qe5
Additional fees:
Estimated value of work is required(if over S5,000):S Application accepted:
(M•ithin the public night-of-way) By: '5-W Dare:
Application reviewed:
Is work related to a LAND-USE DL''CISION? ❑ Yes Ll No
13y: Date: 1 p-2Ar-1 I
If so , please speciR (It11.P,SI R,SUB, etc.) case #:
• Applicant notified:
Is work related to a BUILDING PERM117? ❑ Yes D No By: LZ Datc: ca
If so,please spcclf),(13UIL13ING case#: I:\ENG1PermitAppticitions\pfl application Rev.12/16/2016
Cityof Tigard - 1312;SWI hall lilvd. - Tigard,Oregon 97223 - wvvwtigard-orgov - 503-718-2421 - Page 1 of 4
APPLICANTS
NOTE: Person specified as`.-Applicant" shall be designated"Pertnittee"and shall provide linancial assurance ti)r work, 1►'
rctluIred by Ilie city I)ursuant to TMC 15.04 1.1411.
111111 the exception of a ulilitn•()[.)Ll-ating pursuant to a valid franchise%,.itlt the City of'I'igard,'when the owncr and the applicant arc different
"11Ic,the applicant must he the purchaser of record or a Iessce in posscssmtl With myrittcn authorization from the o,tncr or an agent of the
(rUrler. '111c rnrner,$)must siy11 this application in the spare pnivided or suhmit a wittcn authorization with this application. I-ranchised
I tilities.arc lith 1-c'itIln11 to 1-1It.1111 the i-atu•r's>i�n:uun 4It1 the applicatVm
M* SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT:
• IJhc above requcIt doers not violate am rcatrdcd decd restrictions that may be attached to()r imposed upon the,lrbicct
I1ro lcrn.
• It' Ilie application is granted,the applic;all \t Ill c-ze-rrl<c• 111c ritiltts granted in accordance wt111 Ill(' It•rnls and subject to all tic
c"nditions and limitations o1 the ahprcn al.
• .111 of Iic abox,e statements and the statetllcnts in ;Illy blot plan,attachments,altd exhibits transmitted hcrewith,are true;and
tic applicants so acknowlcclgc that any permit issilud,based on this application,may be revoked if it is found that ally slrch
tatcnlents arc fare.
• I is applicant has read the entire contents of the application,including the policies and criteria,and understands the
1,c(luire111ct1ts for:tpprol'tllg or deliving the application.
NAck If 0 S;R,V-A' �-CL- \j G Irl
d 1-11
.Applic: :Authorized:Agent's t`nature Print nattrt� Date
SIGNATURES of catch owner of the subject property, if required.
)WneC s stgllal urc h-int name Date
f hviler's signature 1,1"I11t I1;1111C Dare
C )wlicr's sig aturc 1)1'111t 11a111c late
PU,BLIC FACILITY IMPROVEMENT PERMIT
(.It\- Of Ti-ard • 1 ,l 2; 11:111 i;lvd. • Tigard,Oregon 9722; • -,v\\•kt•.ilgard-or.goy 1 ti 2421 • Page 2 of 4
DEVELOPMENT ENGINEERING FEES
FOR STAFF USE ONLY
Public Facility Improvement(PFI) Permit:
DETAILED
SUBMITTAL
APPLICATION FEE REQUIREMENTS
Part 1: Required subtnittal fee S300.00
FRANCHISE UTILITY AND SIDEWALK/
PERMIT FEE DRIVEWAY AND UTILITY
Part 2: x111 non-water system imCONNECTIONS,ETC.provements (work in the right of way)
Engineer's estimate X 5%(less S300.00 submittal fee)
Engineer's estimate X 2%Plan Review Sketch
(including information below)
WATER SYSTEM FEE ❑ Dimensions
Part 3: All public water system llllpt'ul•ements ❑ Street Name
Engineer's estimate X 12'ln ❑ Site Address
PFI Permit Fee Exemptions: FULL SCALE DEVELOPMENT
There will be no pc:rnlit fee charged,or assurance required
(Subdivisions/Partitions and Street lmprc�verncnts)
for the following types of work:
• Sidewalk repair(less thin 20 lineal feet)
• Relocate or replace mailbox Design Plans
• Ditch cleaning that does not involve regrading. (G sets,2406 or?2x34)
• \Veep hole repair ❑ Cover—Site,Vicinity,Abbreviation,Legend
• Curb repair or replacement (less than 20 lineal feet) ❑ General Notes(City,Water,Sewer,etc.)
• Lawn sprinkler s}stem installation or repair ❑ Street(Plan,Profile)
• Street tree pruning or planting ❑ Water,Storm and Sanitary=(Plan Profile)
• Planter strip landscape maintenance ❑ Water Quality Facilities
• 'fest wells ❑ Grading
❑ Landscaping/Tree Plan
❑ Composite Utility Plan(Electrical,Phone,Gas,
Note: A casb 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 1312:1 SW Hall Blvd. • T1gard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 3 of 4
basic Communications
Contracting Inc. � ��,
(360) 314-4454verwa-
Li
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if 2p M,
fL4 0° §
a�
t
2011 Edition
Page 77
Short Duration Road Work Diagram 200
1 t
Work Vehicle
(Optional)
* 3 or more cones �--- _ ROADS ,
may be placed • — - '' WORK
behind vehicle
• * AHEAD
for added visibility \
Vehicle mounted
(Optional)
I
1 mile maximum
r` ROAD
--— ---- WORK
AHEAD
Initial Warning Sign
(Optional- See Note 6)
September 2016
Chanter 5
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
Check(✓)one
REFUND OR Name: Heidi Sellick
INVOICE TO: (Business or Individual) Linescape,LLC
Mailing Address: 19100 SW 51St Avenue
City/State/Zip: Tualatin, OR 97062
Phone No.: (971) 804-1496
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#: PFI2017-00231
Site Address or Parcel #: SEG954
Project Name: Comcast
Subdivision Name: N/A Lot #: N/A
EXPLANATION: Customer accidentally paid for another customer's permit. Please issue
100% refund. Thank you!
Date: 10/26/17
Signature: C
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.
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date
Refund Processed: Date L A Invoice Processed: Date B
Permit Canceled: Date AJIj B Parcel Tag ridded: Date B
I:\Building\Forms\RegPcrrnitAction_092314.doc
q
City of Tigard
November 20, 2017
Linescape,LLC
Attn: Heidi Sellick
19100 SW 51"Ave.
Tualatin, OR 97062
Re: Permit No. PFI2017-00231
Dear Applicant:
The City of Tigard has processed a refund for overpayment of permit fees on the above
referenced permit for the following:
Site Address: SEG954
Project Name: Comcast
Job No.: N/A
Refund: ® Check#226761 in the amount of$300.00.
❑ Credit card "return" receipt in the amount of$
❑ Trust account"deposit"receipt in the amount of$
Notes: Refund application fees paid in error on the wrong permit number.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Coordinator
Enc.
I:\Bui1d1ng\Refun&,3Un }ice ,*p3yigaMi gon 97223 • 503.639.4171
TTY Relay: 503.684.2772 0 www.tigard-or.gov
_ City of Tigard
Accela Refund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must
be attached to this request form. Refund requests are due to Accela System Administrator by
each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: Linescape, LLC DATE: 11/6/2017
Attn: Heidi Sellick
19100 SW 51't Ave. REQUESTED BY: Dianna Howse
Tualatin, OR 97062 LS
TRANSACTION INFORMATION:
Receipt#: 413553 Case#: PFI2017-00231
Date: 10/26/2017 Address/Parcel: SEG954
Pay Method: CreditCard Project Name: Comcast
EXPLANATION: Refund 100% of application fee as customer paid for another customer's permit fees on
the wrong permit number in error.
REFUND INF". 1 N.
Fee Description From Receipt RevenueAccount No: Refund
=
j3qjldipg Permit Fee Exam le: ,2300000-43104 $Amount
PFI Permit Fee 100-0000-43114 $300.00
TOTAL REFUND: $300.00
APPROVALS: SIGN U ES DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager
If under$25,500 Department Manager
If under $50,000 City Manager
If over$50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: By:
I:\Building\Refunds\RefundRequest.doc x 09/01/2010
CITY OF TIGARD RECEIPT
12 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Project Name: Comcast
Site Address:
Receipt Number: 416581 - 04/06/2018
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12017-00231 $-300.00
Tota I: $-300.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 226761 DROWSE 04/06/2018 $-300.00
Payor: Linescape LLC
Total Payments: $-300.00
Balance Due: $300.00
Page 1 of 1
CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
Project Name: Comcast
Site Address: e��1'67/Alit-t--
Receipt
Receipt Number: 413553 - 10/26/2017
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12017-00231 PFI Permit Fee 100-0000-43114 $300.00
Total: $300.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Credit Card 07960G PUBLICUSERO 10/26/2017 $300.00
Payor: HEIDI E. SELLICK
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1