PFI2017-00237 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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Rcqucst for Permit Action
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13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • www.dgard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@dgard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor [City Staff
Check(✓)ons
REFUND OR Name:
INVOICE T O• (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED {✓):
CANCE OID PERMIT APPLICATION.
ND 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 #:
Site Address or Parcel #: ,b lif &VVh"10r, q-no l
Project Name: C -
Subdivision Name: �,W -Ttrrktt LmLot #:
EXPLANATION: All o� 41, Wick bev- if� PF12it-ootn� �w X41,% ljidow I,
V F1 1 -002-S I. trt�& 11."0 0 'I'S no lin,v. Auar W %,,' t n K11 fir`
Signature: Date:
Print Name: �4tiMJe �d�t�Q„
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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: Date4v / B
Refund Processed: Date/1`4/ By Invoice Processed: Date B
Permit Canceled: Date �? B rcel Ta Added: Date B
I:\Building\Forms\RegPermits
tAcon_0 2314. oc
RECEIVED
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City of Tigard , <:: d D 0 C T 2 3 2017
PUBLIC WORKS — ENGINEERING /2-12,41- 17
s
ARD
Public ]Facility 1mprovementP44W19eTTM_
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way) ❑ TYPE 1—Franchise Utility Work
Check one: R Utilities ❑ Sidewalk/driveway approach ❑ Street improvements performed by NWN, PGE
Detailed description: Comcast is proposing to pull a new fiber optic cable and/or utility agency.
through existing 2"conduit and construct new underground conduit with a ❑ TYPE 2—Sidewalk/Driveway/Sewer
fiber optic cable within the City of Tigard ROW Work performed for the purpose of:
• Sidewalk installation or repair.
Property address/location(s): 17026 SW Friendly Ln • Driveway approach installation
and/or repair
• Sanitary sewer lateral installation
and/or main line tap
Applicant:
Comcast Cable ❑ TYPE 3—Full scale Development
Work performed with Land use
Address: 11308 SW 68th Parkway approval which includes any of
City/state: Tlgard, OR Zip: 97223 the following:
Phone: 503.596.3817 Email: Jason_mcdonald@comcast.com • Subdivisions or Partitions
Jason McDonald 503.596.3817 • Street widening
Contact name: Phone:
• Mainline installation for Sanitary
Contractor: Tennessee Cable Services sewer, Storm sewer, Tigard water
CCB#: 77450 Expiration: 10/25/2019 and/or Tigard Water Service Area
Address: 17035 SE Evergreen Hwy SUBMIT COMPLETED APPLICATION TO:
City/state: Vancouver, WAZip: 98683 City of Tigard
360 696-8900 tenncs aol.com/beavrebuild aol.com Planning/Engineering
Phone: � ) Email: @ @ 13125 SW Hall Bbd.
Contact name: Terry Richmond Phone: (503)969-6792 Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: K&B Technical Solutions only may be emailed to:
Address:
6566 SE Lake Rd rowpermits@tigard-or.gov
Milwaukie, OR 98632
FOR STAFF USE ONLY
City/state: Zip.Phone: 503.650.6041 Email: glen_williams@kbmail.net Case No.: P)Ek.�,� �
Contact name: Glen Williams Application submittal fee: $ ""
Additional fees: $
Estimated value of work is required(if over$5,000):$6,041 Application accepted:
(within the public right-of-way) By: k1Q Date:
Is work related to a LAND-USE DECISION? ElYes ElNo Application reviewed:
If so, please specify (MLP, SDR, SUB, etc.) case #: By Date: +{tT•, -7
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes ❑ No By Date:
If so,please specify(BUILDING PERMIT)case#: I:\ENG\PermitApplications\pfi application Rev.12/16/2016
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 APPLICANTS) 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.
Digitally signed by Glen Williams
Glen WilliamsouemallG-'glenwillams@kbmaiilnel`aUs'u"°"S Glen Williams (For Jason McDonald) 10/20/2017
Date:2017.10.20 09:19:18-07'00'
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 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.
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: 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)
• `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 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 • wwwtigard-or.gov • 503-718-2421 • Page 3 of 4
SAMPLE SKETCH:
Edge of Pavement
I
Ditch �
Streetlight
PAM Dwam
F�.rTrek- 41
10 a 1
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' T"'Vro ja os +cMower"ri e"
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C,I Existing House
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Existing Shop I
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7'ropertyLine
I Fire Hydrant(FH)
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Scale: 'I"=30'
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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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