PFI2018-00234 VOIDED
PF12018 - 00234
City of and T1 • COMMUNITY DEVELOPMENT DEPARTMEN
Tigard �.
A/-
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 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
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 #: PF12018-00234
Site Address or Parcel#: 11395 SW Ironwood Loop
Project Name: Moen Driveway Replacement
Subdivision Name: N/A Lot#: N/A
EXPLANATION: Per applicant,property owner no longer wants to do this project. Please
void permit and$300 invoiced fee. Thank you.
Date: 10/31/2018
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 ONL
Route to Sys Admin: Date 13Y Route to Records: Date // /Er /¢ B
Refund Processed: Date N B Invoice Processed: Date B
Permit Canceled: Date 611(o / B arcel Tag Added: Date B
I:\Building\Forms\RegPemutAction_( 2314.doc
RECEIVED
City of Tigard
•�' `� PUBLIC WORKS — ENGINEERING SEP 0 5 2018
Public Facility Improvement PFI Permit
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
y [I TYPE 1-Franchise Utility Work
Check one: ❑ Utilities Sidewalk/driveway a proach ❑ Street improvements performed by NWN, PGE
Detailed description: ee,Ian �� U0&& and/or utility agency.
;�j TYPE 2—Sidewalk/Driveway/Sewer
Work performed for the purpose of:
Sidewalk installation or repair.
1
��j5- �,- ��/�:�� li�%v/�' • Driveway approach installation•-
Property address/location(s): ,U / UV ' ` and/or repair
° -� Sanitary sewer lateral installation
and/or main line tap
❑ TYPE 3—Full scale Development
Applicant: �� Work performed with Land use
Address: approval which includes any of
City/state: Zip: the following:
Phone: Email: • Subdivisions or Partitions
c� Contact name: Phone: • Street widening
• Mainline installation for Sanitary
sewer, Storm sewer, Tigard water
Contractor: /^ /- T- ' L d7 and/or Tigard Water Service Area
CCB#: Expiration: gfgt4
U
Address: SUBMIT COMPLETED APPLICATION TO:
.f'
City/state: e �. Zip: City of Tigard
�— Planning/Engineeting
Phone: 't (�-- 75&mail: or��/d el CCAS f YitC (Ct'1 l3�" � r 13125 SW Hall Blvd.
Contact name: , Phone: �!� "�Q'� Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: only may be emailed to:
rowpermitsktigard-or.gov
Address:
FOR STAFF USE ONLY
City/state: Zip: ,p
Phone: Email: Case No.:
Contact name: Application submittal fee(.007%of
Engineer's Estimate)
Estimated value of work is required(if over$5,000):$_ Additional fees: $
(within the public right-of-way) Application accepted:
`
Is work related to a LAND-USE DECISION? F-1Yeso By: t (- Date:
If so, please specify (MLP, SDR, SUB, etc.) case #: Application reviewed:
By: Date:
Is work related to a BUILDING PERMIT? ❑ Yes XNo Applicant notified:
If so,please specify(BUILDING PERMIT)case#: By: L�_Date:
I:\ENG\PermitApplicat ions\pfi_ap piication Rev.10/16/2017
rn,ro
City ofTigard • 13125 SW Hall Blvd. Tigard,Oregon 97223 www.tigard-or.gov • 503-718-2421 • Page 1 of4
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
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 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
req ents for approving or denying the application.
;�SI7744
pplicant/Authorized Agent's signature Print name Date
SIGNATURES of each owner of the subject property, if required.
00VA LD o 6L) Wt
Owner's signature Print name Date
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Ow is 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 of4
DEVELOPMENT ENGINEERING FEES FOR STAFF ITSE ONLY
Public Facility Improvement(PFI)Permit:
DETAILED
APPLICATION FEE REQUIREMENTS
Part 1: Required submittal fee$300.00 (minimum) FRANCHISE UTILITY AND 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
❑ 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 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) (4 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 ❑ 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(pro)ect land use name,revision and
plan log block,dates and sheet numbers.)
❑ Engineers Construction Estimate
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 Provider Approval
PUBLIC FACILITY IMPROVEMENT PERMIT
City ofTigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 3 of4
SAMPLE SKETCH:
Edge of Pavement
I
I — Ditch
Streetlight I
Rain zrain _
1 I =ri 0 1
I I •
' T"rr o p os c1�5'ej�nre rT ii a"_ 1
� I T
1 (3) IN� I 1
.N Existing House
Existing
I g
>I Driveway .
75101
I 1
C 1 R I �•
0 1 ., 1
01
0I
1
Existing Shop
Powerpole I = I C'
,•., o . o
I I a 1
g5' 1'------- ------—---
I -Trroperip L ni e.
1 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 ofTigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 4 of4
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