PFI2018-00163 VOIDED
PF12018 00163
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City of Tigard * COMMUNITY DEVELOPMENT DEPARTMENT 2
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Request for hermit Action
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • w�k-NX.tigard-or.gor
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 KCity 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.
F] 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#: ' IS - UDUa
Site Address or Parcel #: P&Ae-,
Project Name:
Subdivision Name: Lot#:
EXPLANATION: I(1l U i rz�
Signature: Date:
Print Name: V
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
Route to S s Admin: Date B Route to Records: Date B
Refund Processed: Date /VBy Invoice Processed: Date B
Permit Canceled: Date ' ,;L//.` B Parcel Tag Added: Date B
I:\Building\Forms\RegPermitAction_ 92 14.doc
RECEIVED
City of Tigard V 0 D JUN 2 6 2018
PUBLIC WORKS — ENGINEERING � CITY OF TIGARD
PLANNING/ENGINEERING
Public FacilityImprovement (PFI) Permit
DESCRIPTION OF WORK(in the right-of-way) TYPE OF WORK
Check one: (�} (utilities ❑Sidrualk/dtiveaav approach ❑ TYPE 1-Franchise Utilitt-\ ork
pp ❑Street improve men performed by NWN, PGE
Detailed description: fI 1& f_,,wj and/or utility agency.
TYPE 2-Sidewalk/Driveway/Sewer
Work performed for the purpose of:
• Sidewalk installation or repair.
Property address/location(s): J/yi3 7 OR,`j C- /71w3 • Driveway approach installation
and/or repair
Sanitary sewer lateral installation
_ and/or main line tap
Applicant: Zrfzo �,� '�ian �� ❑ TYPE 3-Full scale Development
Address: _ �� �`Ox ZG�ei Work performed with Land use
approval which includes an),of
City/state: �S7� �. Q Zip; U the following:
Phone: - 22' k Email: Y, Subdivisions or Partitions
Contact name: #_ _�rA' #..- Phone:�3 - Z-�3/ Street widening
• Mainline installation for Sanitary
Contractor: �`,GC /��vt � sewer, Storm sewer, Tigard water
CCB##; Expiration: —2-LZa.P and/or Tigard Water Service Area
Address: SUBMIT COMPLETED APPLICATION TO:
City/state: �' o� Zip; -
City of Tigard
r
Phone: i'T 47,1AT31Email: Planning/Engineering
- 13125 SW Hall Blvd.
Contact name: ✓� —'' Phone: 503'y2 Z-9 3
'g Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: only may be emailed to:
Address: "limmermit4ne d-or gov
City/state: Zip: MOTO
Phone: Email: t
Case No.:�I _nWL0
Contact name:
Application submittal fee(.007%of
Engineer's Estimate) $
Estimated value of work is required(if over$5f)00): 3Sb0� Additional fees: $ -
(within the public right-of-way) ,
Application accepted:
Is work related to LAND-USE DECISION? ❑ Yes ,B No B}' Date:
If so,please specify (MI.P,SDR,SUB,etc.) case #: Application reviewed:
Br. Date:
Is work related to a BUILDING PERMIT? ❑ Yes JO No Applicant notified:
If so,please specify(BUILDING PERMIT)case#: Bv: AL.- Date:
1:1FHG1PHmitAppNot7onslyR_1pplk•10" Aev.10/16/2017
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���` �C� "CityofTigard 13125SWHallBlvd. Tigard,Oregon 97223 • www.dgard-or.gov 503-718-2421 Pagelof4
DEVELOPMENT ENGINEERING FEES
Public Facility Improvement(PFI)Permit:
APPLICATION FEE
Part 1: Required submittal fee$300.00 (minimum) FRANCHISE UTILITYAND SIDEWALK/
DRIVEWAY AND UTILITY
PERMIT FEE CONNECTIONS,ETC.
Part 2: All non-water system improvements (work in the right of way)
Engineer's estimate X 5%(less$300.00 minimum
submittal fee) Sketch
(including information below)
Engineer's estimate X 2%Plan Review
D Dimensions
WATER SYSTEM FEE ❑ Street Name
Part 3: All public water system improvements ❑ Site Address
Engineer's estimate X 12%
FULL SCALE DEVELOPMENT
PFI Permit Pee Exemptions: .(Subdivisions/Partitions and Street Improvements)
There will be no permit fee charged,or assurance required
for the following types of work: Design Plsne
• Sidewalk repair(less than 20 lineal feet) (d sets,24X36 or 22x34)
• Relocate or replace mailbox ❑ Cover—Site,Vicinity,Abbreviation,Legend
• Ditch cleaning that does not involve regrading. ❑ General Notes(City,Water,Sewer,etc)
• Weep hole repair ❑ Street(Plan,Profile)
• Curb repair or replacement(less than 20 lineal feet) ❑ Water,Storm and Sanitary(Plan Profile)
• Lawn sprinkler system installation or repair ❑ Water Quality Facilities
• Street tree pruning or planting 0 Grading
• Planter strip landscape maintenance ❑ Landscaping/Tree Plan
• Test wells ❑ Composite Utility Plan(FlectdcA Phone,Gas,
Storm,Sanitary,Water,Signage,Street lights,etc)
❑ Details
Note. A cash/bond assurance may be ❑ Traffic Sight Distance
required per TMC 15.04.140. ❑ Signing and Striping
(eusromer deposit) ❑ Street Tight Plan and Photometric
❑ Engineers seal/signature
❑ Sheet label(project land use name,revision and
plan log block,dates and sheet numbers.)
Additional Submittals
(per Land Use conditions)
❑ Traffic Report
❑ Storm water Drainage Calculations
❑ Geotechnical Report
❑ Preliminary Access Report(Sight Distance)
❑ Proposed Plat
❑ Pathway Design(f applicable)
❑ Water Department Approval
❑ Engineers Construction Estimate
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard 13125 SW I fall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov 503-71$-2421 • Page 3 of4
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