PFI2019-00136 CityofTigard • COMMUNITY DEVELOPMENT DEPARTMENT 1
446-
z. Request for Permit Action /'`'l�� `
TIGARD 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 1=/ 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 (1):
Er 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).
p
Permit#: ' 2-Vol-olDO I 2,&
Site Address or Parcel#:
Project Name:
Subdivision Name: Lot#:
EXPLANATION: DVpS cot}C' rrruA "— ci veetctkl Gre e f-
?FP-DR-Dot 39
Signature: A `-- Date: 1-1131)(1
Print Name: 41'S LI►LOIZ
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 12 Route to Records: Date(o/, 7 /9
Refund Processed: Date /4/4- WieL Invoice Processed: Date By
Permit Canceled: Date /f 7/15, By,,efr Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_1 051 .doc
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City of Tigard J r q `y RECEIVED
IIII - WORKS —ENGINEERING + '
=. PUBLIC o APR 2 2 2019
T l G A R D Public Facility Improvement (PFflPrrthi
,w_r.. D' NIN IENQFERJ gz.
; ;ru TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way) CM TYPE 1—Franchise Utility Work
Check one: ❑ Utilities ❑Side.. 11;/a-:._..ay approach ❑S.--eet^:pr. .,.-...rte performed by NWN, PGE
Detailed description Temporary crane activity for tree removal and/or utility agency.
❑ TYPE 2—Sidewalk/Driveway/Sewer
Work performed for the purpose of:
• Sidewalk installation or repair.
• Driveway approach installation
art
Prnny addresc/locatint,(�l 151IR SW Kanton Dr.
r---� � / and/or repair
Tigard, OR /�.� • Sanitary sewer lateral installation
and/or main line tap
..1....
NessCampbell Crane + Rigging ❑ TYPE 3—Full scale Development
Applicant - Work performed with Land use
Address: 573n NP 138th Ave approval which includes any of
City/state Portland, OR Zip:97230 the following:
Phone: 971-221-4663 Emai11:L.BROWNaNESSC^.7PBELL.COM _ • Subdivisions or Partitions
Contact name: Lee Brown Phone: 971-221-4663 • Street widening
• Mainline installation for Sanitary
Contractor: sewer, Storm sewer, Tigard water
and/or Tigard Water Service Area
CCB#:' Expiration:
Address: SUBMIT COMPLETED APPLICATION TO:
City/state: Zip: City of Tigard
Planning/Engineering
Phone: Email: 13125 SW Hall Blvd.
Contact name: Phone: Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: only may be emailed to:
g rowpermits( tigard-or.gov
Address:
FOR STAFF USE ONLY
City/state: Zip: Q
Phone: Email: Case No.:) F 1 '/ ^vC13
Contact name: Application submittal fee(.07%of
Engineer's Estimate) $
Estimated value of work is required(if over$5,000): $< $5,000 Additional fees: $
(within the public right-of-way) Application accepted: 7
By: Date:
Is work related to a LAND-USE DECISION? ❑ Yes Ni No
Application reviewed:
If so,please specify (MLP,SDR,SUB, etc.) case#:
By: Date:
Is work related to a BUILDING PERMIT? ❑ Yes D9 No Applicant notified:
If so,please specify(BUILDING PERMIT)case#: By: Date:
I:\ENG\PermitApplications\pfi_applicetion Effective 10/16/2017
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 1 of 4
1
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 APPLICANT(S) SHALL CERTIFY THAT:
• The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject
property.
• 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.
Lee Brown 04/22/2019
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 • wwwtigard-or.gov • 503-718-2421 • Page 2 of 4
DEVELOPMENT ENGINEERING FEES FOR STAFF USE ONLY
Public Facility Improvement(PFI)Permit: DETAILED SUBMITTAL
APPLICATION FEE REQUIREMENTS
Part 1: Required submittal fee$300.00
FRANCHISE UTILITY AND SIDEWALK/
PERMIT FEE DRIVEWAY AND UTILITY
CONNECTIONS,ETC.
Part 2: All non-water system improvements ` (work in the right of way)
Engineer's estimate X 5%(less$300.00 submittal fee)
Engineer's estimate X 2%Plan Review I 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
for the following types of work: (Subdivisions/Partitions and Street Improvements)
• 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)
• Weep hole repair ❑ Cover—Site,Vicinity,Abbreviation,Legend
• Curb repair or replacement(less than 20 lineal feet) F ❑ General Notes(City,Water,Sewer,etc.)
• Lawn sprinkler system installation or repair [( ❑ Street(Plan,Profile)
• Street tree pruning or planting '"r'❑ 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
❑ Engineer's Construction Estimate
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 3 of 4
SAMPLE SKETCH:
Cr SW "Y" St
Edge of Pavement
7766‘ '111- Ditch
Streetlight —•—•_----•---- --
Ili
f' Raaf Drain r: i:`s1f 1 fir T i w
® 1 two P,* 4,1
.t y �i6
I
1 T`77•313. srdree1�wer nine-- 1
Ir, 1 I
.ilii Existing House 1
•
vi 1 Existing I
TA • Driveway
�i of I 1
aI St •il
WI I rI
,\> 1
i1 , I
tCla 4
I
a,• II
41 -
Existing Shop I
J
\ i
Powerpole I = I a) 1
'o •
'`.'''I`it I' 95' 1
I :75" -_-_-Toperly-Line—-—-----—-
I -
I
II Fire Hydrant(FH)
I I
ii
II Scale: .I"=30'
I I
I I
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/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 • wwwtigard-or.gov • 503-718-2421 • Page 4 of 4
I 1 1 2 1 3 1 4 I 5 1 6 i 7 I 8 1 9 1 10 1_
2 EA SIDEWALK CLOSED TYPE 3 �
2 EA ROAD WORK AHEAD
1 EA ROAD CLOSED AHEAD
A 2 EA ROAD CLOSED TO THRU TRAFFIC TYPE 3 A
4 EA ROAD CLOSED TYPE 3
B B
— ROAD ROAD
WORK WORK
AHEAD `>AI AO"..
C C
ROAD
CLOSED
f' AHEAD;
D D
•ao.aogEoro 41
ROAD ROAD — r eu°Lra°nFFic° —
s
L00ALA�s 8 CLOSED CLOSED c ccess •
oN r E o Lv
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/6m
E E
ROAD
WORK.'...
AHEAD
F F
DATE TIME —
—
CONTACT
LEE BROWN144'
NESS CAMPBELL CRANE
0 L.BROWN@NESSCAMPBELL.COMlir
N G
971.221.4663 NESS CAMPBELL
SHEET
1 OF 1 CRANE + RIGGING NOT TO SCALE; ADJUST TO FIELD CONDITIONS
-1 1 I 2 1 3 1 4 1 5 i 6 1 7 i 8 i 9 1 10 1