PFI2017-00248 City of Tigard • COMMUNITY DEVI:LOPTNIENT DFTi\RTMENT
Request for Permit Action
13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503-718-2439 • Nyww.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 9City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKEFACTION FOR THE ITEMS) CHECKED (✓):
CANCE OID PERMIT APPLICATION.
___❑ D 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#: P-�—1 U 1-1-
Site Address or Parcel#: S G,
Project Name:
Subdivision Name: Lot#:
EXPLANATION: QweA Dpyrn It PE!Z�0 j-7-at)zt�l
19 A
Signature: Date: l0 I
Print Name: nif& yc pc
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
ONLY
Route to Sys Admin: Date By Route to Records: Date 12-1 B
Refund Processed: Date/V/`, - B Invoice Processed: Date B
Permit Canceled: Date �l B Parcel Tag Added: Date B
1:\Building\Forms\RcgPcrmitAction_09231 .doc
City o,f Tigard VO I D
q PUBLIC WORKS ----ENGINEEIUNG Q2,/ 1.//2
Public Facility ImpPermitrovement (PTI}
TYPE OF WORK
DESCRIPTION OF CORK(in the right-of-way)
❑ TYPE 1-Franchise L'tilir % csrk
I
�'
Check one: ® Utilities ❑Side-w-Ak/drive vay approach ❑Street improvements perfurmed by NWN, PGP,
Dctailed description:TO BORE IN 1.25"CONDUIT AND FIBER ABOUT 40'ACROSS and/or utility agency.
SW FONNER ST.AT DEPTH OF ABOUT 36"PATH FROM POLE 30886 TO PROPERTY ❑ TYPE 2-Sidewalk/Driveway/Sewer
Work performed for the purpose of
LINE BETWEEN 10700 AND 10720 SW FONNER ST. SidewAk.installation or repair..
10700 SW FONNER ST. Drive«:�y approach installation
Property address/location(s):loeatic�n(s): and/or repair
�,.4 1 Sanitary sewer lateral installation
and/or main line tap
FRONTIER COMMUNICATIONSMOHN COUSINEAU ❑ TYPE 3-Full scale Development
Applicant: Vlork performed with Land use
Address: 4155 SW CEDAR HILLS BLVD spproval which includes any of
City/state: BEAVERTON Lip: 97005 the following,
Phone: 503-643-0371 l-�,mail: John.cousineau@ftr.com • Subdivisions or Partitions
JOHN COUSINEAU . 503-643-0371 • Street widening
Contact name: i bout.
• Mainline installation for Sanitary
Contractor:
SONICOM sewer,Storm sewer, Tigard water
and/or Tigard%Yiater Service Area
CCB#: 188116 rxpira tion: 09/24/17
Address: 1275 S Kodiak Circle SUBMITCOMPLETED APPLICA'T'ION TO:
Citi'/state: CORNELIUS/OR. Zip: 97113 City of Tigard
Phone:503-519-3445 ],m;til:PJfe[lows@sanlcomoorp.com I'Irtttning/E»gtnPettnR
1312,5 SW Hall Blvd.
Contact name: PJ FELLOWS Phone: 503-992-7711 Tigard,OR 97223
Applications fi)r"min(jr Nvork in right-of-%vay'
F,n)oneer: JOHN COUSINEAU only inay be emailed to-
rownermits cr tigud-or.gov
Address: 4155 SW CEDAR HILLS BLVD.
City state: BEAVERTON/OR. 7,ip: 97005 FOR STAFF USE ONLY
f Q
Phone: 503-643-0371 Email: lohn.cousineau@ftr.com Case No.:T- 12xr1-00 L�1-149
Contact natne: JOHN COUSINEAU Application submittal fee:
Mditional fees:$
Estimated value of work is mquired(if over$5,000):$ 3,000 application accepted:
(aJithiri the public ri,ht-of-way) Bv: �— Date: I 1
Is work related to a LAND-USE DECISION? ❑ Ya; FYI No Application rcwicwed:
BY. are,:
If so,please specify,- NILP,SDR,SUIS,etc.) case#:
Applicant notified:
Is work related to a BUILDING PERII�iIT? ❑ Yes Ll No B4. Date:
If so,please specific(BUILDING PERMI'1)Case#: t'\Er%WermitApPbcatlaalp6_apakation Rev.12/16/2016
City of Tigard 13 135 SW Hall Blvd. • Tigard,Oregon 97223 - «%-\%t igard-or.gov • 503-715-2421 - 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 citta pursuant to'f 11IC 15.041.140.
With the exception cif a utility(ipctnting pursuant to a Valid franchise With the Cin•of'l igard,when tilt:owner and the applicant arc tliltcrent
peopic,tilt:aiplicant must he the purchaser of record or a Ies-,ec in lx)saesaion with Written authiiriiation fain►(lie owner lir an al ent of the
owncr. "Ilse owncr(cl must sigh this appliattion in the sptcc provided or submit a written autht»iiation with thiti appliatt.itm. Franchised
Utilities are not required to nUtain the teener'~signature tin the application
BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT:
• The above request clues not violate ani recorded Gleed restrictions that mai-be attached to or imposed upon rhe_suhiect
rte.
• If the application is grunted,the applicmit will exercise the rights gTantcd iii 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 transinitted herewith,are true;and
the applicants so acknowledge that any permit issued,based on this application,may he revoked if it is found that any such
statements are false.
• 1he:applicant has read the entire contents of the application,including the po icies and criteria,and understands the
requirernents for approving or denying the application.
00000
r
JOHN COUSINEAU 91106117
A )licant/Authorized Agent's signature Print name Date
SIGNATURES of each owmer of the subject property,3i£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 • 1.3125 SW l tall lih.-d. • Tigard.0rego n 9 722.E • wwwtigard-or..gov 503-719-2421 • Page 2 of 4
DEVELOPMENT ENGINEERING FEESFOR STAFF USE ONLY
Public Facility I;nprovement(PFI)Permit:
DETAILED "
REQUIREMENTS
APPLICATION FEE
Part 1: Required submittal fee 5300.00
FRANCHISE UTILITY AND SIDE TALK/
PERMIT FEE DRIVEWAY AND UTILITY
CONNECTIONS,ETC.
Part 2: All non-xsa3tcr.s�stein improvements (work in the right of way)
Engineer's estimate X 5`Yt,(less$300.00 submittal fee)
Engineer's estimate X 2%Plan Review Sketch
(including information belo""
WATER SYSTEM FEE ❑ Dimcns.ions
Part 3: All public Mater.system Improvements ❑ Street Name
Engineers estimate X 120 i� ❑ Site Address
PFI Permit Fee Exemptions: FULL SCALE DEVELOPMENT
There.-ill be no hermit fee charged,or assurance required
(511
for the fOROwing types of work: 11d1vitiit)nS/i'lrritlt)ns and Street Improvements)
• Sidewalk:repair(less than 20 lineal feet)
• Relocate or replace mailbox Design Plans
• Ditch cleaning that does not involve regrading. (G sets,2406 or..2x34}
• 'Weep hole:repair ❑ Cover—Site,Vicinity,Abbreviation,Legend
• Curb repair or replacement(less than 20 lineal feet) ❑ General Notes(City,Water,Saver,etc)
• Lawn sprinkler system installation or repair ❑ Street(Plan,Profile)
• Street tree pxtiniug or planting ❑ Water,Storm and Sanitary(Plan Profile)
❑
• Planter strip landscape ma intenance Ga di Quality Facilities
• Test wells ❑ Gracling
❑ Landscaping/Tree Plan
❑ Composite Utility Plan(Electrical,Phone,Gas,
Note. A cash assurance»lay he required per Sturm,Sanitary,\X%ter,Sicgwn c,Strccr lights,etc)
TMC 15.04.140.(customer deposit) [3 Details
❑ Traffic Sight Distance
❑ Signing and Striping
❑ Street U ht Plan and Photometric:
❑ l?ngincers seal/signature
❑ Sheer label(project land use cisme,revision and
plan log block-,dares and sheet numbers.)
Additional Submittals
(per Land Use conditions)
❑ 'Traffic Report
❑ Storm nater Drainage Calculations
❑ Geotechnical Report
❑ Preliminary:Access Report(Sight Distance)
❑ Proposed Plait
❑ Pathway Design('if applicable)
❑ \Fater Department Approvatl
�.tx±t�wr�:.+Asn_�!�vr_sr�rirMz;s^t�7�t�o- �rs!r�.. .=�:: �u^.rr.�crr�xers�.�a�e+ro�rr .. .. . . .�w�+��.'��:v:,!.�sr*,:a�x'm�r..r„es•;�-��`z;eut
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard 13125 SW l loll Blvd. • 'Tigard,Oregon 97223 • www tigard-o.r gov • 503-718-2,121 • Page 3 of 4
SAMPLE SKETCH:
W.
I Edge of P aventent
I
Ditch
Streetlight I •----►•--■�a4NOW•POW•--■—r---
Rain.Drain
�`
1 0
� I
' T"'p'r oE�os c!'"�evv`-er■"Ci rt a"` �
CU,
1 .Uj Eycieting House
4 i I Existing �
I I
>m Driveway
O ^ I
a.
I � .
�7 I Existing Shop`
'
MICL
Powerpole [
I --......----7ropertyLrne---------.....-
Fire Hydrant(FH)
I I I
Scale: 'I"=30'
I I .
I I
� I I
� I f
MINIMUM SKETCH REQUIREMENTS(Put"N/A"if Not Applicable):
North arrow Property: lines c`L-.dimension Slope of property
Street &street naine(s) Existing building,structures Utility&street light poles
Proposed Existing curb or edge 'frees
I_xisting S/W or of pavement Existing utility*locations
D/fit'apron (saver,water,storm)
ldallSX�r'isdRS'^ W'.�!��.b`:—`+.e�"'`J..�"'�L�`7.6"La_�Jf!`!:�[9' 7'R.•t1",..Q!$Y!'.�l'L'L__1+2'+_:.YJ.YYS'�'.L^�^'?.:JSCS"..TR'EGYf�JS-1!'�...��..YY_''tP'TSR'Meb39�=3I7tS'�A�'Y!2CYC'."P1'F�'"n,3n1„'w'R4`C.MW� l:K•!:!'r��'kP�=P!b:lNxSl�'IlklgAf?"..C77dL'i9hp
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard - 13125 SW I[all Blvd. - T' ard.Orcgoii 97223 - m%\,xvtigard-or..gO v - 503-718-2421 0 Page 4 of 4
N
BSW Commit Date: 2017-11-06
Cust TN: 5035981030/0
Cust Name: ABIGAIL REEKIE
Addr: 10700 SW FONNER ST , PORTLAND, OR A
County/Twp: /0009-7223 cam, -r,•.,. a� 1 "e{�R,� :��tc
CBR: 5038582321 '
CO- BBFTP
Commit Date: 2017-11-07
O/T: Order
C/F: Fiber
Drop Typ�: Buried �•.�" �'�
Temp: No
Drilled Entrance:No �j`' ` 1C 10720
Drop Length:
Cross St: (n -
Appr Drop Rte: I
Hub: BBFTP/H4008 O RAW
Strand: ry
!'ort: 248 ry SW FONNER ST. 40'
Serv. Term: BBFTP/FT-45824 PORT: 248 w R/W
TERMINAL 45824
Drop Term: 10705 SW FONNER ST PRT,OR 3:
Notes: INSTALL DATE 11/07/17 13:00 17:00 C/} POLE 30886
JOB COMPLETE DETAILS
DATE: NAME: 1�`�`tl, -► TICKET: EXCH:
P 59 DW BORE: LS BORE: SW BORE:
P 50 DIRECT BURY:
P43D PULL:
P 77 CORE DRILL: Y N QUANTITY: 1 2 3 4 5
P 16C GROUND ROD: Y N QUANTITY: 1 2 3 4 5
P71A
TRIP CHARGE NOTES: 09A NCJT 60 e4 e % C .5S
-
Y N
L 10A
P 22 K
P36B
- c C vi is oN ,I'C;Lt _�