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PFI2020-00135
CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT qNI COMMUNITY DEVELOPMENT Permit#: PF12020-00135 R D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 04/13/2020 Parcel: SEG2395 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: NW Natural Project Description: Annual valve inspection at various addresses. Class of Work: FEES Type 1 - Utilities(gas, electric, data) Description Date Amount PFI Permit Fee 04/09/2020 $300.00 Owner: Total $300.00 REQUIRED INSPECTIONS Call 503-639-4175 for the IVR inspection request line or visit the City of PHONE: Tigard website at www.tigard-or.gov to schedule inspections online. Contractor: PHONE: Applicant: DAN HACKER 220 NW 2ND AVE PORTLAND, OR 97209 PHONE: 5032264211 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- elppLiLi c,/ L. f�l �J Issued By: `!f)0J"J !Vv9•� Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PFI2020-00135 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 ADVANCE WARNING Applied Notice Advance warning of traffic disruption shall be provided to the public by placement of an approved advance notification sign at each end of the construction area 72 hours(min.)before initiation of construction work, PFI_Utilities 09-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 10-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 11 -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 12-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 13-DRAINAGE CONTROL Applied Notice Drainage shall be controlled within the work site and shall not adversely affect adjacent private property, public property and the receiving system. The City may at any time order corrective action and suspension of work to accomplish effective drainage control. PFI_Utilities 14-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 15-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 applicants expense. Changes must be approved by the City in advance of work.Applicant shall coordinate the work with affected utility agencies. PFI_Utilities 16-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 17-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 19-PRECONSTRUCTION MEETING Applied Notice Before initiating any construction activity,the applicant shall coordinate with the City's inspector, Trent Brickey at 503-718-2686,to establish a preconstruction meeting. PFI_Utilities 20-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 21 -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 22-DAILY INSPECTION REPORTS Applied Notice Applicant shall submit daily inspection reports,on a weekly basis,to the City's Inspector. PFI_Utilities 23-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 24-VALIDATION OF MATERIAL/CONSTRUCTION Applied Notice The City's Inspector may, at his discretion, require tests and or reports from the applicant to validate claims of material or construction adequacy/compliance. Such tests/reports shall be provided at the applicant's expense. PFI_Utilities 25-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 26-RIGHT OF ENTRY/EASEMENTS Applied Notice Applicant to obtain proper right-of-entry and/or easements prior to starting work. Proof of right-of-entry or properly executed easements,shall be provided to the City. The City shall in no way be construed to be liable for the applicant's failure to obtain or provide for proof of right-of-entry or easements. PFI_Utilities 27-PRIVATE PROPERTY AGREEMENTS Applied Notice Provide the City a copy of an executed agreement[s]from the owner for each private property disturbed by construction activity. PFI_Utilities 28-AS-BUILT DRAWING Applied Notice 1,2,3,4,5 28-AS-BUILT DRAWING One as-built drawing showing all new public improvements, including any revision made to the previously approved construction plans and, also, any improvement which may impact an existing public system or facility, shall be provided to the City by a registered civil engineer along with an engineer's certification of installation compliance(Certificate of Compliance). 1,2,3,4,5 28-AS-BUILT DRAWING One as-built drawing showing all new public improvements, including any revision made to the previously approved construction plans and,also,any improvement which may impact an existing public system or facility, shall be provided to the City by a registered civil engineer along with an engineer's certification of installation compliance(Certificate of Compliance). One as-built drawing showing all new public improvements, including any revision made to the previously approved construction plans and,also,any improvement which may impact an existing public system or facility, shall be provided to the City by a registered civil engineer along with an engineer's certification of installation compliance(Certificate of Compliance). PFI_Utilities 31 -OTHER Applied Notice Other RECEIVED City of Tigard APR G 8 2020 pH#: 2020 00135 ENGINEERING DEPARTMENT CH Y t F T!GARD P INNING/ENGINEERING 1 H Public Facilities mprovement (PF1) Permit PROJECT INFORMATION TYPE OF WORK Project name: 3604953 R TYPE 1—Franchise Utility Work Brief description of project: Annual valve inspections at various addresses. performed by NWN,PGE, or utility agency No digging or cuts required.See attached for details. T TYPE 2—ROW Sidewalk/Driveway/Sewer Work performed for the purpose of: • Sidewalk installation or repair • Driveway approach installation and repair SITE INFORMATION • Sanitary sewer lateral installation and Various addresses,Tigard main line tap Location (address if available): 9 r TYPE 3—Pull Scale Development Work SEG2395 performed with land use approval which includes any of the following: • Subdivisions or Partitions APPLICANT INFORMATION • Street widening NW Natural • Mainline installation for sanitary sewer, Name: storm sewer, Tigard water, and Tigard Mailing address: 250 SW Taylor St water service area Portland, OR 97204 I— TYPE 4—Small Cell Technology City/State: Zip: E TYPE 5—Tigard Triangle Phone: 503-226-4211 x4461 Email: djh@nwnatural.com Phone: 800-882-3377 NOTE: Type 1 and 2 applications may be Contact name: Dan Hacker emailed to rowpermits@tigard-or.gov. Phone: Same Email: Same CONTRACTOR INFORMATION E Same as applicant Name: Same CCB Number: Mailing address: City/State: Zip: Phone: Email: ENGINEER INFORMATION Name: Rich Girard Mailing address: Same City/State: Zip: Phone: 360-921-0314 Email: r2g@nwnatural.com ADDITIONAL INFORMATION Estimated value of work is required(if over$5,000):$ (within the public right-of-way) Is work related to a LAND USE DECISION? C Yes -No Case number: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • 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 city pursuant to TMC 15.04.140. * With the exception of a utility operating pursuant to a valid franchise or license 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 must sign this application in the space provided or submit a written authorization with this application. Franchised or Licensed Utilities are nor required to obtain the owner's signature on the application. I,the applicant,certify that: • To the best of my knowledge, all the information provided within this application package is complete and accurate. • 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, I will exercise the rights granted in accordance with the terms and subject to all the conditions and limitations of the approval. Dan Hacker 4/8/2020 Applicant's or authorized agent's signature Print name Date Property owner's signature (if required) Print name Date STAFF USE ONLY Case No: PF12020-00135 Permit fee: ZOO. OD Received by: SW Date: 4/8/20 Approved by: - Date: yf q/2oda Notified by: At-y Date: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-otgov • 503-718-2421 • Page 2 of 4 DEVELOPMENT ENGINEERING FEES Public Facility Improvement(PFI)Permit: INITIAL PFI PERMIT FEE Part 1: Required submittal fee is 10%of the Net PFI Permit Fee.See below for calculations.Minimum of$300. NET PFI PERMIT FEE Part 2: All non-water system improvements engineer's estimate X 7%(less the initial PFI Permit Fee). WATER LINE CONSTRUCTION FEE Part 3: All public water system improvements engineer's estimate X 12%. FOR STAFF USE ONLY FOR STAFF USE ONLY TYPE 4: SMALL WIRELESS FACILITY TYPE 1—3:DETAILED SUBMITTAL CHECKLIST REQUIREMENTS Does applicant have a right-of-way license? I Yes No TYPE 1 AND TYPE 2-Must include a sketch showing: Under the wireless facilities standards,is the proposal [ Dimensions considered?(check all that apply): Small Cell Macro I- Street Name How many install sites are proposed as part of this permit [ Site Address application? TYPE 3-Must provide 4 sets of plans (sized 24 x 36 or 22 x 34) and an electronic version of all submittal The proposed equipment is located on which of the following: items. The plans must that include: Public Right-of-Way Private Property L Cover—Site,Vicinity,Abbreviation,Legend If equipment is to be located on private property,describe the L General Notes(City,Water,Sewer,etc.) type&use: L Street(Plan,Profile) L Water,Storm and Sanitary(Plan Profile) L Water Quality Facilities L Grading L Landscaping/Tree Plan L Composite Utility Plan(Electrical,Phone,Gas, Storm, Sanitary,Water,Signage,Street Lights,etc.) L Details [ Traffic Sight Distance L Signing and Striping [ Street Light Plan and Photometric I— Engineers seal/signature I^ Sheet label(project land use name,revision and plan log block,dates and sheet numbers.) [ Engineer's Construction Estimate Additional Submittals (per land use conditions,if applicable) [ Traffic Report I- Storm water Drainage Calculations L Geotechnical Report L Preliminary Access Report(Sight Distance) [ Proposed Plat [ Pathway Design L Water Provider Approval City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 3 of 4 `1- ,. 1- ,. s l Edge of Pavement �� Ditch �� Streetlight �•�•�•�•�•�•, •— r r 1 - 0lI .1 T'Fi5�Sar/d"S�40grrif�'_ 1 t, I 1 1 r I () 1 , V Existing Hm :e 1 >o Drivewayit 'i I ,• I '''...1,. �1 P a l . J`'P 1 3' I ;I I I o l 1 Existing Shop 1 1 G e • J t I�Pi_werpole r I 1 \ I' 95' 1 1 doper 'Lme— — IIN I - l 0 1 Ftre Hydrant¢H) I I l I Sale I"=30' l 1 l I I I I I TYPE 7 AND TYPE 2: MINIUM SKETCH REQUIREMENTS (Put N/A if not applicable) North arrow Property lines&dimensions _ Existing utilities locations (sewer,storm,water) Street&street names All existing structures Proposed work Existing curb or edge of pavement Utility&street light poles Existing S/W or D/W apron Slope of property Trees City of Tigard • 13125 SAS'ILA Blvd. • Tigard,Oregon 97223 • ww tigard-or.gov • 503-718-2421 • Page 4 of 4 www.invarion.com 1 } 1 I 1 1 e3� i 1 I I WALE][MOTTO el I a C 01 C W U Q T K W U CO C W lu a x o 2 2 N M 1 4 1 ROM W20-3 W20-3 eM) 1 4 } 1 Q 1 } }\ W20-3 E --______--":„ K ,-ROAD-A T >- CLOSED C Cl) 1 41 4 ca. 1111111111111, NM.NW Natural -- PLEASE SCHEDULE WITH DISPATCH Legend TONprn EL 103,1214207 WNW LONA n"""ADVAHuuRI PRONDa RI Type 3 Road Closed I.Maintain Pad scam w S03-228-1111 • orOHIAOLPLUEDTNMSO 20 owlo Ytl wauo°+nlb co,T C01mLVLPLAN ®W20-3 road closed ahead Low LOCATIO SW RDV IOMSDS LN 3.M.IMIn Leatl.0 SW ROT M0ER0 R l!WD1k Area .,30.0.,SMmC PI°".M°II noun ORO ®Wort Truck N.HN OW mewl., 01 Aa and M OTT00 CH WO DATE w0R tad°pot. - E..DEVICE'MOW: 011020 SHERW000 NEa Y ON pawn.VISO 0°IIM FIN UN.'ID' �ael p3 ma..nen7m UIMNO M who own.euel b w. rw,w.1dCSL1EJd1VJ a w Nagmnl N,putll o.ASE potted LONE.SO M".M M11YM ppNeE helm,wmelNN".lgI_ Match to page E.1W.woo TMs'. owl noun from IN Traffic EryLnw M3 WoOs ,,�: hwPCIH"ANLIh.TMP.YOMP 834 C..01 and; INVENTORY:Inme 7 SOW Won al•contrelial Il ,.,,,•unj,tl;;o'1"HP'°"'R°"N°t MVOSRISME MO POURSnHWM e.PYuNoPahbpgmHhnln 130 1•TYPE III BARRICADE RD CLOSED mm u Ref MVTc0 x00sM olnp. ra$000N0E N•eMe. n. _=.._. 1 D.A,NtLO IOW condition. 3-ROAD CLOSED AHEAD www.lrw•donwm • 350' 0 CW9-3 W20-1 A « f + SW DURHAM RD ' SW DURHAM RD r r N1Iar•: = © fiir RWORK OAD O \ AREA• 3SO MONITOR ONSITE TO ADJUST CONTROLS AS NEEDED W4.119 B ASSIST PEDESTRAINS AROUND WORKZONE W20-1 CW1-4 [TYPICAL INVENTORY: Rao e.Ix.pr.p•rs,oI tn.[relic CUSTOMER: Legend control plan makes nOr.pr....aum NW Natural 2-ROAD WORK AHEAD •e m m approvedesosrs1 rot im eaguaaY v wppr 1-CENTER LANE CLOSED AHEAD 0 CONE astoitarlmpl..Mbvp..Approval must*Mar result from t o•Tnm<...m er CONTACT 1-SHIFT SYMBOL ®CW74 revere curve a an.r public official n.vlep.Nen.ry Katie Llebert 145-ARROW ..rorewnant RaW.dry a Me 503-226-4211 30-CONES ®CW9-3 center lane closed ahead lmpSer..ntlonoae.n and ImpNmentetan pl Ns plan shall be as Keep Left W4-119 •noun of that approval. LOCATION: Rel.WITCO 2009 0Ad111ek 9450 SW DURHAM RD NOT TO SCALE A0er TIGARD OREGON ®W20-7 road work ahead PLEASE SCHEDULE WRH DISPATCH Si Work Area TI HOURS0003423VANCE MO DATE: WOE: Work Truck PRONDE A COPY DP THE APPROVED 03-10-20 SUNSET TRAMS CONTROL PLAN valve 10: NOTIFY ENSWRE WV POLICE Tt 1-047-030-9-01-V-A HOURS SS ADVANCE Nate: 1-047-020 Match to page p;A,,p,Ep #35 o1n. .. .4.41249.1 ca � . www.invarion.com 350' w20-I T to to v m 14 MONITORONSITETOASSIST I , •PEDESTRIANSS AROUND WORK AREA I AT / Oaan W�LLK + fIv ® n■ 4 4 i c` ...will. -®� ow-122 350' W2o-2 a a r t g f SW DURHAM RD s► 0 y SW DURHAM RD — P -- - t I1111.11111111 35P } W20.1 OW-In • • •• • •ado.1 M• c VRROWBOARDI h tt CM w4-2 2544 CO 0Z D 350 O 1 D m I 350 } . 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Ny.ID: PLFABE 6CEWLEMIx DISPATCH 1-W501SRY1-VS onOi•O nn PI+F: i / M0noIOOA0500AAPme Wr�Roven 4-ROAD WO: da./ , RUR0 C0x0ROL PIM 4-ROAD WORK AHEAD 1aRsaTRo1 'Sv i • /t 4-RIGHT LANE CLOSED AHEAD / v'e' w.oe. ,'4� ,4 1-DT 1-ARROW BOARD Mw w� / 30-CONES - �� ° d / 1-BIKES ON ROAD 1-TYPEIII KEEP LEFT am' WIS ...l.r-can ;IGllllllllllllllxllllllllti -- �e • a�- _ - 'F r"` 1 x1 xunxnxmxlnnml/�, \, —_ �Wle. ow-1n 11 a/ t�r/ �f'.' wzla �� 1 '7 / .a/,Is ',/ °wy N.I 71 _ N TIGARD City of Tigard August 13,2021 NW Natural Attn: Dan Hacker 250 SW Taylor St Portland, OR 97204 Re: Permit No. PFI2020-00135 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: SEG 2395 Project Name: NW Natural Job No.: N/A Refund Method: ® Check#240241 in the amount of$240.00. ❑ Credit card"return"receipt in the amount of$ . Note: Please allow 2-5 days for this refund transaction to be credited to your account by the company that issued your card. ❑ Trust account"deposit"receipt in the amount of$ . Comment(s): Per applicant's request to cancel permit and refund 80%of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Ornelas Building Division Services Supervisor Enc. 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard-or.gov I Ph City of Tigard 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 forPermit Action 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: NW Natural DATE: 8/6/2021 250 SW Taylor St Portland, OR 97204 REQUESTED BY: Dianna Ornelas TRANSACTION INFORMATION: Receipt#: 428974 Case#: PFI2020-00135 Date: 4/9/2020 Address/Parcel: SEG 2395 Pay Method: CreditCard Project Name: NW Natural EXPLANATION: Per applicant's request. Refund 80%of permit fees. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 2300000-43104 $Amount PFI Permit Fee 640-0000-43114 $240.00 TOTAL REFUND: $240.00 APPROVALS: SIGNATURES/DATE: If under$5,000 Professional Staff If under$12,500 Division Manager If under$25,000 Department Manager If under$100,000 City Manager If over$50,000 Local Contract Review Board FOR ACCELA SYSTEM ADMINISTRATION USE ONLY Case Refund Processed: Date: <///Z/ By: I:\Building\Refunds\RefundRequest.doc x 09/01/2010 trCity of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT RECEIVED " Request for Permit Action APR 27 2020 TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • wwW. �III�^^OF TIGARD K111 YENGINEERING '1'0: CITY OF TIGARD \/c2 t D Building Division t (, /2/ 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner El Applicant ❑ Contractor ❑ City Staff Check(i)one REFUND OR Name: INVOICE TO: (Business or Individual) NW Natural Mailing Address: 250 SW Taylor St City/State/Zip: Portland, OR 97204 Phone No.: 503-226-4211 x4461 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): 001 CANCEL/VOID PERMIT APPLICATION. p rg REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). Permit#: PFI2020-00135 & PF12020 90148 Site Address or Parcel#: Various addresses Project Name: Subdivision Name: Lot#: EXPLANATION: NW Natural will not be doing these inspections in Tigard. Rip—rand)N.D k0 /o r -( P E-,2.r L I-1— to —s t -1.4_ Signature: / Date: 4/24/2020 Print Name: Dan Hacker 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. —1 206 tQU ZKo , CZ) /LsF i--141 -6 tr ) FOR OI'1'ICE USE ONLY Route to Sys Admin: Date By Route to Records: Date f' /B Zj By .J Refund Processed: Date j `7d By.s�/ Invoice Processed: Date By Permit Canceled: Date(�/2i / l t/yJ By,00 Parcel Tag Added: Date By 1:\Building\Forms\RegPe nutAetion_420518/doc PhCITY OF TIGARD RECEIPT 4 g 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: NW Natural Site Address: /)r/-,J Receipt Number: 435817 - 08/13/2021 xG CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12020-00135 $-240.00 Total: $-240.00 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 240241 DHOWSE 08/13/2021 $-240.00 Payor: NW Natural Total Payments: $-240.00 Balance Due: $240.00 Page 1 of 1 , CITY OF TIGARD RECEIPT i 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Project Name: NW Natural Site Address: j /Y// ( , .�l/'L Receipt Number: 428974 - 04/09/2020 fJ ! CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12020-00135 PFI Permit Fee 640-0000-43114 $300.00 Total: $300.00 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 6253428 PUBLICUSERO 04/09/2020 $300.00 Payor: Total Payments: $300.00 Balance Due: $0.00 Page 1 of 1