PFI2020-00421 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
. COMMUNITY DEVELOPMENT Permit a: PFI2020-00421
A R D 13125 SW Hall Blvd..Tigard OR 97223 503.718.2421 Date Issued: 11/17/2020
Parcel: 2S 103 BC05700
Jurisdiction: Tigard
Site address: 12255 SW TIPPITT PL
Subdivision: TIPPITT PLACE Lot: 7
Project: Block- 12255 SW Tippitt PI
Project Description: Reroute sanitary sewer thru basement via open trench/drill, connect to main on 12275, and new tap,
insert a tee
Class of Work: FEES
Description Date Amount
Type 2-Sidewalk/Driveway Approach PFI Permit Fee 11/17/2020 $300.00
Total $300.00
Owner:
REQUIRED INSPECTIONS
Call 503-639-4175 for the IVR inspection request linear visit the City of
PHONE: Tigard website at www.tigard-or gov to schedule inspections online.
Contractor:
BLACK ROCK UNDERGROUND LLC
267 NE 34TH PLACE
HILLSBORO, OR 97124
PHONE: 5037479312
Applicant:
DREW MCVEY
267 NE 34TH PLACE
HILLSBORO, OR 97124
PHONE: 5037479312
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
�l_p��f
Issued By: ArafA "Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PFI2020-00421
Tvoe: Condition Name: Status: Severity:
PFI_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalkl[ 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_Sidewalkl[ 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_Sidewalkl[ 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_Sidewalkl[ 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_Sidewalk/[ 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_Sidewalkl[ 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_Sidewalkl[ 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_Sidewalkf[ 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 applicant's expense. Changes must be approved by the City in advance of work.Applicant shall coordinate the work
with affected utility agencies.
PFI_Sidewalkl[ 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_Sidewalk/[ 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_Sidewalk/[ 18-SEWER SYSTEM TEST Applied Notice
A sewer system air-test and/or DVD T.V.test report and one set of"As-Builts"shall be provided for review and approval.
PFI_Sidewalk/[ 19-PRECONSTRUCTION MEETING Applied Notice
Before initiating any construction activity,the applicant shall coordinate with the City's inspector, <Trent Brickey>at
<971-228-9269>,to establish a preconstruction meeting.
Please call 503-639-4175 to schedule inspection, use code 738
PFI_Sidewalk/[ 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_Sidewalk![ 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_Sidewalk/[ 22-DAILY INSPECTION REPORTS Applied Notice
Applicant shall submit daily inspection reports,on a weekly basis,to the City's Inspector.
PFI_Sidewalk![ 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_Sidewalk/[ 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_Sidewalk![ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 28-AS-BUILT DRAWING Applied Notice
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_Sidewalk/[ 31 -OTHER Applied Notice
Other
City of Tigard M■ per ; 2020-00421
I:Nc1NP.ER1Nc DFPARTMFN'C
Public Facilities Improvement (PFI) Permit
PROJECT INFORMATION
R ` 'I'l FE OI'VI ORK
Pn1jvct name: M�� \' ' ` 155 5u t pQ, f !{`— f TI'I'I. I I r.tn<'•...tu i 111111 1\.44.
(lccC 1419c1 Rluutn t)f rnirrt•14 t15(AC. ,v t�IN(�7( S C.'� ,� (x rh pn ny)I, \t4\,Ka .n tttiFa,
ApitAri
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• Ilterw:r Approach uerallamm and ri
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APPLICANT IN FOR\1 ATION • Sun l aritirnint
` U n 9 _ L L c. • Nl:nnlinc tnxt,tUation tor Anita() sctiat.
Namr: it?1C,� dC V�.'�LtW'�\C T�)O1V ' Munn ..vcr. Tiµ(d uaw .. wki Twt(I
Mailing adds , "1.W-1 l'\) e 3 !. 11 V 1 q1 aykr�rt.titc six*
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1] TYPE S-'1 q ud'1'naai4k
Phi inc: -
l:mail: Phone: NOTE: Type I end 2 derlicatiun► mill be
coward in pm-ti-r•n;;duv%'.ed.r Lti e1_
(:nntact name:
Phone: Email:
CONTRACTOR INFORMATION \lil,Sane as applicant q
Name: _S G.ws. �S h�� C`.CR Number: Ail� 1 I_ f _—
Mailing itkk., City/State: _ % 1
Phone: '. M"14"l 'CV- IC4% I:mail: 1 Y11 o P I)\o+tr..4'o c\.0 r\I (opt ou4a.c 4►e%
ENGINEER INFORMATION J
Name:
Mailing address: City/State: lip:
Plume: Email:
ADDITIONAL INFORMATION V t
I:.stimawd value of work is required(if over55,11I111):5 I (within the public right of way)
Is work related to a LAND USI. 1>I.(V isit lN1 0 1'cs El No Case number. ,
City of Tigard • t 112i SV I IA I41.(1 • 'I y.1n1.Ot(ie'•I`)''t i • tu...ltwain-i.r.l!„( • S1t(.'11N 2-01 • Page I of4
APPLICANTS
NOTE: Peron sis cifwd as"Applicant"shall he tksi}ntated"1'ermittec"and shall pnn irk financial assurance fee
work,if required by the city pursuant to•I M( 15d4.S40.
' 1t'att ht tutproN t.t a unhn,ixratng NMI]Mt In a nrlkl trafuir. ce 4et n+. r nh oho.t :e it,1 W10,a hen rho Ira ncv arki f!11 applicant
ac d;ffin•ia pit.rk.Iht apphtatw mini 1m tilt panh■`t of n.-twat ur a kt.es In 1101,a.wn1 uah anncn autlnFtlutatn tnwn'ha tlworf
Iw an awn ui the 4mtitc. Tx uttner MUM •'F"rhos application in the vac( pr.a,t.hd.w a.asrint a*norm auth.atralil.m Iauh thes
.ppda a+.vwt tlanch» it ow I atnnMri I tiltin.Art CAN tu4Iutr.UI lit 44441e1 Ilk l erne.opaillrt.al the appltcatu.n
I, the applicant,certify that:
• 'I'o the best of it knowledge,all the infOrmatism 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 prtpcny.
• If thy application is granted, I will.\c r Ise the rights granted in accordance with the terms and subject to all the
conditions and limitations of the apprtot al.
Ipplic. nt'c r.r:unbaru gent. •urc Print nantc ) t)u c \61,0
Property owvcr's signature (if rcyutrt:d) Prim name I).tic
•- r \i I nNI
Case No: PFI2020-004221 Permit fee. 20•00 Received by: LS Date: 1 /4/20
Approved by: 71E44 eitin> ,y Date: aJfl�f?ozv Notified by: Date: 11 1�
City of Tigard • 11125 SU I Ian IllsJ. • Tigard.(ingot* ; • %* st:tugani,.r.yr,t • Ste i• IS 24?I • Page?of 4
DEVELOPMENT ENGINEERING FEES
Public Facility improvement(PFI) Permit:
INITIAL PH PERMIT FEE
Part 1: Rupuuecl submittal fcc is Il11. of Ilx Nct PI t Pcmat I'ct.See below for calculations.Minimum of$300.
NET PEI PERMIT FEE
Pan 2: .Nil ntrn-water system impnivctncnrs engineer's estimate X«' {less thc initial Pit Permit FcY).
WATER LINE CONSTRUCTION FEE
Part 3: 1U public water s5 stem rmprt tt t.'nwnts engineers estimate X 12 4.
I•(R siAI FUSE'ONLY I tin st \I I t 'I. 1.1\1.1
TYPE 4:SMALL WIRELESS FACILITY TYPE 1-3:DETAILED SUBMITTAL
CHECKLIST REQUIREMENTS
Dots ap=phenol it.tt a tight t.t wai hc.nscr Li Yes iJ >0 I \ PI.. I AND TYPE 2-Mu+sr iurlu,k a ,Lc1,11
showing{:
Linder Ow wireless facilities standards,is thc proposal [j I)itncnsft•ns
ctmaaktedl`r (cheek all that appklL ❑Smaii("ell 0 3itter.t ❑ Stitt t Xanu
low man) install noes areprttpxsocd as pan.,f thit pr:nun ❑ Sits Addnss
ap rrihtant Kt?
'TYPE 3- Must provide 4 sets of plans (sized 24 z 36
or 22 x 34) and an clecrrnnpc version of all submittal
The proposed cqurpmcnt is k.cattti on shah of thy hallowing; items. The plans must thal include:
❑Public Right-of-Way 0 Private Nolan!,
Li t-+toes—hoe,\'tt"Itun, \hhn:stati n,Iegend
If equipment a to be hosted on pxit'Ite property,dtscnbt +kt 0 (:corral\ntcs{C:ar,\1 nu,Sestet.rte.)
n px&u.c: 0 Strtct(Plan,Pntfiik)
❑ 1\'atcr,Strom and Sanitary(Plan Profile)
❑ Water(Malin l acil+nics
LI (unsling'
❑ Iamltcaptnk/ I ter Plan
❑ Comp,wat I'Mitt Plan tl'Icctrical,Pht roc,(eas,Siu not.
Bataan.\\stet,Sip;nagc,Strtct I.tghts,cit.)
❑ pcea1s
❑ Truth:Sight l)stancr
❑ Signing anti Striping
❑ Srrtct light Plan and Phttttantrnr
❑ Engineers seal/*two tuft,
O SItvt lahcl(pmticct land uvc runt,tars MI MI and plan
log Ialock,dates and sheet numbers 1
❑ Ett inrrr's(ittfxirurnon Flatmate
Additional Submittals
(par bated u¢ amdititwrs,if arphcahltl
O Traffic Report
❑ `;bongo water t)rainage(ac wlartun.
❑ Cktrtcchnicsl Regain
❑ Preliminary Access Report(Sight i istatncc'
❑ t rstd Plat
❑ Pathw^as lacsikn
C3 \\'aftr Provider Approval
Gin of Tigard • 111.25,S1\ I lall ItIttl. • Tigard,r trcgnn 9-22+ • tt,vw•.I:y,atd„t,p;,,t • 3111 71F 2121 • Page3 of 4
Location: /22Ss" SW Tier,;?- Pl. 116"O Name: aoe t3wcL . c'i7 ° Date: 9 3o- 20
Point of Access:
Pipe Type:
o
:sa4� ° a Depth At Home: Li •
r \ '�` 1'1155 Depth at Curb:
-
`^ -' ,t U°' Depth At Main: S'G ''
_
S ____IMachine Access:0 N
c 0,
yo 6.5 O Roots O Pooling O Off-Sets
,I.
0 w't`` 0 Cracks
9.
9' 14 �,� Repair Type: ont'N 'Ptv.ic4 /PRILc
"' Length of Repair: U'oPe"Mcwca
I60 ' pa,u_
Notes:
Margaret Garza, Ex Offices Receipt#: 937894 Receipt Date: 11/13/2020 01:18 PM
Washington County Clerk Station: 30 Cashier: M FERNANDES
155 N 1st Avenue Suite 130. MS 9
Hillsboro, Or 97124 Receipt Name: BLOCK, ROBERT L
PHONE 503-846-8752 FrIf f ►61d 60.se ela]
Comments:
RECORDING
Document# Recording Date Doc Type Recording Survey Housing A&T Fund NonStd Other Subtotal Transfer Total
2020-115302 11/13/2020 01 16.48 PM D-E 15.00 5.00 60.00 11.00 ...27 70 S9' 03
Totals: $15.00 S5.00 $60.00 511.00 S0.00 50.00 $91.00 $0.00 S91.00
Thank You
Retain this receipt for your records
Receipt Total 591.00
CREDIT CARD 3792907649 $91.00
Page of 1