PFI2018-00266 99 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12018-00266
. � 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 10/02/2018
Parcel: SEG2444
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: PGE
Project Description: Adjacent to 15974 SW 76th Ave. Install underground service to new 2,500-square-foot home Conduit
was installed several years ago across SW 76th Ave. PGE Job M2400632.
Owner: FEES
Description Date Amount
PFI Permit Fee 10/02/2018 $401.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
STEVE HURSH
10800 SW AVERY ST
TUALATIN, OR 97062
PHONE: 503-464-7777
Total $401.00
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: See application
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12018-00266
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.
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
RECEIVED
City of Tigard O C T 0 12018
PUBLIC WORKS —ENGINEERING CITY OF TIGARD
�:.
Public Facility 1mprovcmerft "/j)GRftMit
TYPE OF WORK
DESCRIPTION OF WORK (in the right-of-way) JA
TYPE 1—Franchise Utility Work
Check one: V Utilities ❑ Sidewalk/driveway approach ❑ Street improvements performed by NW N, PGE
Install underground service to 2500 s ft home and/orutiliht agency.
Detailed description: 9 g
Conduit was installed several years ago across SW 76th Ave. ❑ TYPE 2—Sidewalk/Driveway/Sewer
PGE Job M2400632 Work performed for the purpose of:
• Sidewalk installation or rep=air.
• Driveway approach installation
Property address/location(s): 1597 SW 76th Ave � ! and/or repair
Tigard, OR 97224 --9 • Sanitary sewer lateral installation
and/or main line tap
Applicant: Portland General Electric ❑ 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 Gip: 97062 the following:
Phone: 503-464-7777 Email: preregcoord@pgn.com Subdivisions or Partitions
Contact name: Steve Hursh Phone: 503-672-5409
• Street widening
• Mainline installation for Sanitary
Contractor: NSA sewer, Storm sewer, Tigard water
and/or Tigard Water Service:area
CrCrB#: Expiration:
Address: SUBMIT COMPLETED APPLICATION TO:
City/state: Zip: City of Tigard
Planning. gineemng
Phone: Email: 13125 SW Hall Blvd.
Contact name: Phone: Tigard,OR 97223
Applications for"miner work in right-4--way"
N/A only may be emailed to
Engineer: rowpermits(a'.,tigard-or.gov
:'address:
FOR STAFF IJSE ONLY
City/state: Zip:
Phone: Email: Case Into.:7 E/ Cie`�� p
Contact name: application submittal fee(.007%of
Engineer's Estimate) $
Estimated value of work is required(if over$5,000):�4, 5,732.29 Additional fees: $
(within the public right-of-way) Application accepted:
Is work related to a LAND-L15E DECISION? ❑ Yes No BST: " Date:
If so, please specify (MLP,SDR, SUB,etc.) case #: Application reviewed:
By: 8 E Date: d
hhe
Is work related to a BUILDING PERMIT"? ❑ Yes No Applicant notified:If so,please specify(BUILDING PERMti
IT)case#: By: !� Date: w
I:\ENG\PermitApplications\pfi_application Rev.10/16/2017
Citv ofTi gard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 1 of
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.
:1. 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 owncr(s)must sign this application in the space provided or submit a written authorization with this application. Franchised
Utilities arc not required to obtain the owners signature on the application
BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT:
• The above request does not violate an),recorded deed restrictions that may be attached to or unposed upon the subject
proper
• 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 anv 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.
5&0Steve Hursh 10/1/2018
;lpplicant/Authorized Agent's signature Print game I�atc
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 ofTigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2421 Page 2 of
DEVELOPMENT ENGINEERING FEES FOR STAFF USE ONLY
Public Facility Improvement(PFI)Permit:
DETAILED
REQUIREMENTS
APPLICATION FEE
Part 1: Required submittal fee$300.00 (nninimum) FRANCHISE UTILITY AND SIDEWALK/
DRIVEWAY AND UTILITY
PERMIT FEE CONNECTIONS,ETC.
Part 2: All non-water systexn improvements (work in the right of way)
Engineer's estimate X 5% (less$300.00 minimum Sketch
submittal fee) (including information below)
Engineer's estimate X 20,%Plan Review
❑ Dimensions
WATER SYSTEM FEE ❑ Street Name
Part 3: All public water system unprovements ❑ Site Address
Engineer's estimate X 12%
FULL SCALE DEVELOPMENT
PFI Permit Fee Exemptions: (Subdivisions/Partitions and Street Improvements)
There will be no permit fee charged,or assurance required
for the following types of work: Design Plans
• Sidewalk repair (less than 20 lineal feet) (6 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.)
• W'eep 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 ❑ Grading
• Planter strip landscape maintenance ❑ Landscaping/Tree Plan
• Test wells ❑ Composite Utility Plan(Electrical,Phone,Gas,
Storm,Sanitary,Water,Signage,Street Lights,etc)
❑ Details
Note: A cash/bond assurance maybe ❑ Traffic Sight Distance
required per TMC 15.04.140. ❑ Signing and Striping
(customer deposit) ❑ 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
❑ Engineers Construction Estimate
.. ._.. ": .'^'ua�..`.'`,".iR'A`0.� .'... ':.... .:o. ... .. >. . ,. .w:"aA�i;l�«`"•',,:Yad6,e'EG,A.�:^, a�7i74
PUBLIC FACILITY IMPROVEMENT PERMIT
City ofTigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • uu-w-vtigard-or.gov • 503-718-2421 • Page.3 of4
SAMPLE SKETCH:
I
Edge of F avement
-- Ditch
Streetlight ._.,.�.�.�.�.:.�r._. .._
I I
Existing House
Existing •
�+ I >i Driveway
CL
tet!
n
>. I
'I
Q �A Existing Shop �
A •
Powerpole I a
-lop 7y1 7n
� Fire Hydrant(FH)
I
Scale: 'I"=3Q'
� I .
I � �
I �
� I .
I � �
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/\t'or of pay ement Existing utility locations
D/W apron (sewer,water,storm)
PUBLIC FACILITY IMPROVEMENT PERMIT
City ofTigard 13125 SSU Hall Blvd. • Tigard,Oregon 97223 0 wwwtigard-or.gov 503-718-2421 Page 4 of4
77€1 7;'0'i 77,M 683
7635
SINGLE FAMILY LEGEND
NEW PGE FACILITIES TO BE INSTALLED
(UNLESS OTHERWISE SPECIFIED)
.,..,., E
SWALDER ST
1730 SECONDARY VAULT
PROVIDED&INSTALLED BY CUSTOMER
INSTALL 1.4A3 AL•TX SECONf7ARY IN 1-3"PVC CONDUIT
WL.1 -...W.r...... ....- PROWDED 3 INSTALLED BY CUSTOMER
II1Sf X11!:
1 P 7.2 120/240 MP 25KVA NTLB TRANSFORMER __„____w INSTALL 1"#350 AL-TX SECONDARY IN:-3"PVC caNDul,
EXISTING TX HAS BEEN REMOVED PRIOF PROVIDED B INSTALLED BYCUSTOMER
1P 7.2 120/240 MP 15KVATBLB TRANSFORMER LEFT IN DESIGN FOR MAPPING PURPOSE
J
Q
N
CONSTRUCTION NOTES: SFEXT
A 25 C2 1-12C
A 15 43012, __ _.. _ 1. CUSTOMER TO PROVIDE LLTRENCHING AND BACKFILLING.JOINT USE TRENCH
n
Ce- "" A 350 AL-TX FINAL GRADE. TO BE 48 INCHES DEEP AND 30 INCHES WIDE,MEASURED FROM
,5ecvPD-167 .._—
Q w 90 2. CONDUIT(IF NECESSARY)WILL BE GRAY,SCHEDULE 40,ELECTRICAL GRADE.
r PVC CONDUIT WITH NYLON PULL STRINGS(MIN.500 LBS.TEST).
r PGE TO DETERMINE THE SIZE AND NUMBER OF CONDUITS REQUIRED.
r3117p A 350 AL TX I MAINTAIN 12 VERTICAL INCHES AND 24 HORIZONTAL INCHES CLEARANCE
BETWEEN GAS AND OTHER UTILITIES.ALL ELBOWS TO BE 36 INCH(MIN)RADIUS.
- ! ALL BENDS MUST BE FACTORY MADE.RIGID STEEL OR PGE APPROVED FIBERGLASS
BENDS ARE REQUIRED FOR RUNS OF 151 FEET OR LONGER,OR FOR ANY LENGTH
VT-185 ! RUN WITH MORE THAN 180 DEGREES IN BENDS.PVC SCHEDULE 40 BENDS ARE
4996 � VT-305 ACCEPTABLE FOR RUNS OF 150 FEET OR LESS,THE MAXIMUM TOTAL BENDS IN ANY
X CONDUIT RUN IS 270 DEGREES.
200 AMP 3,CUSTOMER RESPONSIBLE FOR ROAD CROSSINGS.USE ONLY GRAY,SCHEDULE 40,
1 1201240 VOLTSELECTRICAL GRADE,PVC CONDUIT WITH NYLON PULL STRINGS(MIN.500 LBS.TEST).
oQ VD-0.754 CP CTICIJrl80RI`aG R. R vTo HD 3; D Pd,li POL E'HE'I Ei C''OR l{f JLE 4 PVC4':IT.A JF- I a di f 7 r�; .F a C:K R t IKF M-CHANICA.Q VF'-3.25CG 'E CN RODUCI; AN 1 E`3NI1€t 10 H llU� H S.L rMEET"-E
N- AIC-4,224 REQ—:14"t MEN r )F FGE S.�.".FV ATIt N L :-1,,f VAI..AL.L.:ON-4ED EST FROM.PGE''RO E-T
EXTR„DWD RED STRIPES(WHICH ISA IFICATI,N REQUIREMENT)MA`.DR=_'EST OF
V UVI
FLP=PIPE;5 REQ..tRED AFTER INS:A: ATIt.N`AITH PGY INSPECTOR FRESPiT
-G4 - 5. SINGLE PRIMARY INSTALLATIONS-CONDUIT TO EXTENDA MINIMUM OF 10'FROM
TRANSFORMER PAD,
Road Side gd'• Spoil 6. ALL PGE TRANSFORMERS TO BE INSTALLED 8 FEET(MIN)FROM ANY COMBUSTIBLE
��Typical BUILDING,WALL OR OVERHANG AND 4 FEET(MIN)FROM ANY FIRE HYDRANT.
PGE TRANSFORMERS MUST BE WITHIN 15 FEET OF A DRIVEABLE AREA.
�® ALWAYS MAINTAIN 10 FEET CLEARANCE IN FRONT OF ALL TRANSFORMERS.
LEGEND RIGHT-OF-WAY PERA41T NOTICE:
PGE Primary 7 7.CUSTOMER TRENCH AND ELBOW CONFIGURATIONS MUST BE INSPECTED BY PGE PRIOR TO
y
O A PERM!!1T FROM THEE OL 1URISDICTION(S QUI 6t-FORL-t AlY BACKFILLING.WHEN YOU ARE READY FOR PGE TO INSPECT(AFTER INSTALLATION IS COMPLETE)
38" 30 O Secondary Cable PCALEASE CAL 503.323.6700 OR 503.4634348(SALEM AREA)
Min Inside Duct WORK IN THE RIGHT-OF-WAYMAY BE PERFORMEE). ONLY PGE APPROVED
Min Cover r ! CONTRACTORS HAVE ALLOW UP TO 2 WORKING DAYS FOR INSPECTION TO OCCUR-
Trench o TelcolCATV COT�'f4AC=L3RS'AhD CCiFrTnAC.LRS WHD:,AVE fvtADE OTHER.SPECLRL
4GREEJOENTS WITH PGE;'VILE.BE ALLOWED TO WORK LINDER PGE`S PERMIT 8. DESIGN IS BASED ON STANDARD UNDERGROUND EQUIPMENT.NONSTANDARD
�
®Backfill THE CONTRACTOR MUST NOTIFY THE LOCAL o3ISDICTION 44 HOURS UNDERGROUND EQUIPMENT MAY BEAN OPTION AT AN ADDITIONAL COST TO THE CUSTOMER.1 D' BEFORE WORK 1,S TO BE OV. A COPY OF THE PERMIT MUST BE ON SITE,
Q D i
Selected Backfill PGE CONSTRUCTION DRAWING
UndisturbedAS-BUILT VERIFICATION&N LATE NS CORRECTED
12"Min Earth 'r.,n•. .._..,:,=+r ...�._.::�..:.... r;=
Foreman: Date:
Joint Use Trench W10 Gas CONTACT SERVICE COORDINATOR General Foreman. Date:
`R.1 R ti({ DU; P`1�{}Y I. (Signature only required For field construcfion than es.)
DEaN � THIS DESIGN MUST Pl T L :F t. SDPMIENG REVIEW. ASBUILT BY DESIGNER:
1-Pr7 DATE. SCALE: ACCOUNT AWD: JOB NO.
BE APPROVED BY THEPGE'PROJECT MANAGER_;, SERVICE COORDINATOR 2/6/2018 1 in:33 ft 1070001 1000004594 M2400632
503-323-6700 OR 503-463-4 3 48(SALEM) TrrLE
LVI CUSTOM CONSTRUCTION LLC
CIRCUIT
CALL 811 BEFORE YOU DIG
ATTENTION: DURHAM-BRIDGEPORT 11 11 x 17
OREGON LAW REQUIRES YOU TO FOLLOW RULES ADOPTED (j`�� LOCATION
BY THE OREGON UTILITY NOTIFICATION CENTER. ■ !'r1 15970 SW 76TH AVE,TIGARD,OR,97224
THINK THOSE RULES ARE SET FORTH IN OAR 951.001.0010 DESCRIPTION
THROUGH 952-001-0090 YOU MAY OBTAIN COPIES OF 1201240 1 P SERVICE TO 2500 SO FT HOME SHEET
SAFETY THE RULES BY CALLING THE OREGON UTILITY t'' COUNTY ISECTIONS WORK WITH
NOTIFICATION CENTER ADMINISTRATION @(502-232-1987) WASHINGTON I C2112C 1 1 OF 1
FIRST TO REQUEST UTILITY LOCATES CALL THE OREGON Knnwwha4'sbetim DESIGNSY PHONE(503)DRAWN BY
UTILITY NOTIFICATION CENTER,811 AT LEAST Call befl3re you dig. Chris Jewett 672-5481 Chris Jewett
@ 1 2 BUSINESS GAYS PRIOR TO EXCAVATION C,PORTLAND GENERAL ELECTRIC CO-ALL RIGHTS RESERVED
------------------------
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VOIDED
PFI2018 - 00266
HAMBACH
GROV
E
3
City of Tigard
November 29, 2018
PGE
10800 SW Avery St.
Tualatin, OR 97062
Re:Permit No. PF12018-00266
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: 15974 SW 76h Ave.
Project Name: Hambach Grove
job No.: N/A
Refund: Z Check#230473 in the amount of$101.00.
❑ Credit card"return"receipt in the amount of$
❑ Trust account"deposit"receipt in the amount of$
Notes: Refund overcharge of permit fees.
If you have any questions please contact me at 503.718.2430.
Since3ply,
Dianna Howse
Building Division Services Coordinator
Enc.
,IXA. 9 1jp&4,69fegon 97223 503.639.4171
L\BuAd1ng\RefundAL25.MY,,U e,, -
T' R F www.tigard-or.gov Y Relay: 98 .44.2772 9 www.ti ard-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 forPenwitAction 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: PGE DATE: 11/16/2018
10800 SW Avery St
Tualatin, OR 97062 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 419715 Case#: PF12018-00266
Date: 10/02/2018 Address/Parcel: 15974 SW 761h Ave
Pay Method: CreditCard Project Name: Hambach Grove
EXPLANATION: Refund overcharge of permit fees per Brady Bullinger.
11 & I h
Cash Over 100-0000-48001 101.00
TOTAL REFUND: $101.00
APPROVALS: SIGN DAIE.
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
Case Refund Processed: Date:
1:\Bading\Refunds\RefundRequest.doc x 09/01/2010
City Of Tigard - COMMUNITY DFIVEL.OPMENT DEIPARTMENT
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 TigardBuildingI'ermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor �City Staff
Check(✓)one
REFUND OR Name: f"1 1
INVOICE TO: (Business or Individual) P/� (AA11we"y Jv '
Mailing Address: /0800 SW ,4V 6e); -r-
City/State/Zip:
City/State/Zip: Fu,a 14t _ ! /, 170 (o2-
Phone
7Q (o2-
Phone No.: Co/ 2. _ 2 ! .✓��
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED4 (✓):
__C.ANCE,L/VOID PERMIT APPLICATION.
REFUND�'ERMIT FEES (attach copy of original receipt and provide explanation below).
-`�""TNVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: {tel'/�Ole - Gid 2 !v 6
Site Address or Parcel #: .SW 76 '~X X ve
Project Name: 32-
Subdivision Name: j�/�a�j�L' RoVi' Lot#:
EXPLANATION: f
Signature: $ yQ Date:/j$'
Print Name:
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. � /) /� �� 7-
FOR OFFICE USE
ONLY
Route to Sys Admin: Date By Route to Records: Date I B
Refund Processed: Date f/ /. B Invoice Processed: Date B
Permit Canceled: Date B arcel Tag Added: Date B
I:\Building\FonnslRegPcrmitAction_Q92314.doc