PFI2017-00144 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
+� v n
Rcqucst for Permit Action 171,,�1,7 io�7j
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tiga� rT d 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: N/A
INVOICE TO: (Business or Individual)
Mailing Address: N/1A
City/State/Zip: N/A
Phone No.: N/A
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#: PF12017-00144
Site Address or Parcel #: SEG3482
Project Name: PGE
Subdivision Name: N/A Lot #: N/A
EXPLANATION: Per Engineering, PFI permit is not required. Scope of work was already
covered under permit no. PFI2017-00071.
Date: 8/2/17
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 /f /`P B
Refund Processed: Date Invoice Processed: Date B
Permit Canceled: Date � Parcel Tag Added: Date B
I:\Building\Forms\ReegPemitAction_0923 f4.doc
rk RECEIVED
N AUG 01 2017
City of Tigard 7
� PUBLIC WORKS —ENGINEERING CITY DE TIGARD
■ PLANNING/ENGINEERING
Public Facility Improvement (PFI) Permit
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
d TYPE 1—Franchise Utility Work
Check one: 16 Utilities ❑ Sidewalk/driveway approach ❑Street improvements performed by NWN, PGE
Detailed description: Street widening-overhead to underground and/or utility agency.
conversion. ❑ TYPE 2-Sidewalk/Driveway/Sewer
Work performed for the purpose of:
- • Sidewalk installation or repair.
• Driveway approach installation
Property address/location(s): _14747 SW 79th Ave and/or repair
_ _ • Sanitary sewer lateral installation
and/or main line tap
Applicant: PGE (Submitted by Dawn Dodds) ❑ TYPE 3-Full scale Development
PP Work performed with Land use
Address: 10800 SW Avery St approval which includes any of
City/state: Tualatin, OR Zip: 97062 the following:
503-612-6055 rere coord n.com • Subdivisions or Partitions
Phone: Email: p 4 @p9
Contact name: Dumitru Ilioi Phone: 503-672-5477
• Street widening
• Mainline installation for Sanitary
Contractor: Portland General Electric sewer, Storm sewer, Tigard water
and/or Tigard Water Service area
CCB#: Expiration:
Address: 10800 SW Avery St SUBMIT COMPLETED APPLICATION TO:
City/state: Tualatin, OR Zip: 97062 City of Tigard
Phone: 503-464-7777 Email: dumitru.ilioi@pgn.com Planning/Engineering
13125 SW Hall Blvd.
Contact name: Dumitru Ilioi Phone: 503-672-5477 Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: only may be emailed to:
rowpermitsCtutigard-or.gov
Address:
FOR STAFF USE ONLY
City/state: Zip: l
Phone: Email: Case No.:
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: k2h Date: f 1
Is work related to a LAND-USE DECISION? S/�-es ElNo application reviewed:
By: Date:
If so,please specify (MLP,SDR,SUB,etc.) case #:
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Nes ❑ No By: Date:
If so,please specify(BUILDING PERMIT)case#: I:\fNG\PermitApplications\pfi_application Rev.12/16/2016
City of Tigard • 13125 SLS'Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov - 503-718-2421 • Page I 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 ant:recorded deed restrictions that mat:be attached to or imposed upon the subject
propeM.
• 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.
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 STAFF USE ONLY
Public Facilitv Improvement(PFI)Permit: DETAILED
SUBMITTAL
APPLICATION FEE REQUIREMENTS
Part 1: Required submittal fee$300.00
FRANCHISE UTILITY AND SIDEWALK/
PERMIT FEE DRIVEWAY AND UTILITY
CONNECTIONS,ETC.
Part 2: All non-water system improvements (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. (G sets,24x3G 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 ❑ `Fater 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:
y ►mow y S t
Edge of Pavement
p I Ditch
Streetlight I ■!■:■i■!■i■!■-■!r!■i
r
Rain Dr:ajn
I I '
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Existing House
Existing
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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 ■ wwwtigard-or.gov • 503-718-2421 • Page 4 of 4
Page 84 2011 Edition
Stationary Lane Closure with Flagging Diagram 320
• Diagram 320 covers total closure of one lane of a two-lane, two-way
roadway. See the detail inset for the layout if using a single flagger to control
both directions of traffic on low volume roads(less than 400 ADT)with good
sight distance as discussed below.
1. Use truck-mounted flashing warning lights on work and protection
vehicles. See Section 4.3—Lights and Lighted Signs for exceptions.
2. For added visibility, a truck-mounted arrow board or PCMS in caution
mode may be used.
3. Flaggers at each approach are required if any of the following
conditions exist:
a. Night Operations.
b. Work space is over 200 feet in length.
c. Sight distance is less than 750 feet from each approach
through the lane closure.
d. Traffic volumes are greater than 400 ADT.
4. The length between the Flagger Ahead signs shall not exceed one
mile. Use Diagram 340—Lane Closure with Pilot Car if exceeding one
mile.
5. Cones should be used to outline the work space when curves or other
roadway alignments prevent clear direction for the motorists to pass
the work space safely.
6. Cones along the work space are recommended when posted speeds
are 45 mph or greater,when working under heavy traffic or when travel
lanes are narrower than 11 feet.
7. Extended queue signing (see Diagram 5-4)should be used when
traffic queues extend beyond the initial advance warning sign.
8. When flagging near an intersection,the"Flagger Ahead" (CW23-2)
sign should be visible to traffic entering from any side road. Additional
advance warning and Flagger Ahead symbol signs may be placed on
the side road(s).
9. Sign set-up and flagger placement shown may be used for intermittent
full road closures of 20 minutes or less.
10. The"ONE LANE ROAD AHEAD" (W20-4) sign is optional and should
be considered on high volume or high speed roads, or when extended
queues are expected.
Chapter 5 December 2011
CD
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