PFI2022-00062 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permitil: PF12022-00062
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 02/28/2022Parcel: 1 S133AD02700
Jurisdiction: Tigard
Site address: 10600 SW SUMMER LAKE DR
Subdivision: AMART SUMMER LAKE Lot: 1
Project: Summer Lake HOA
Project Description: replace 5'6"x8'panel at 10600 SW Summerlake Dr
Class of Work: FEES
Type 2-Sidewalk/Driveway Approach Description Date Amount
Owner: Total
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:
JAY MILLER
8152 SW HALL
240
BEAVERTON, OR 97008
PHONE: 5037074725
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
WA 1
Issued By: ' 9 4Aybt.,
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12022-00062
Type: Condi ion 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_Sidewafk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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—Sidewalk/1 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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—Sidewalk/1 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/1 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/1 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 735
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/1 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/1 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/1 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/1 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 agreements]from the owner for each private property disturbed by construction
activity.
PFI—Sidewalk/1 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
PUBLIC WORKS —ENGINEERING
Public Facility Improvement (PFI) Permit
DESCRIPTION OF WORK(in the right-of-way) 'TYPE OF WORK
Check one: ❑ Utility Connection ❑ TYPE I–Franchise Utility Work
❑�idevrgk/dmvway approach \York performed by Nom,PGE
Strccc imp ents io and/or utility agency.
Detailed description: ���IS{ity � lf/ X �/� E2-Sidewalk/Driveway/Seiner
[cork performed for the purposc of.
• Sidewalk installation or repair.
//�� I�,/1�� Dricca x-, approach installarion
address kxation s): IylaQ0 f u.:�n rniLj'L �L� and/or repair
Sanirary sewer lateral installation
and/or main fine tap
❑ TYPE 3-Full scale Development
Applicant: Rork performed with sand we
Address: l approval which includes any of
the follciving
CitC/state: 1 �Vn Zip: • Subdivisions or Partitions
Phone: Email: • Street widening
Contact name: Phone: • Mainline installation for Sanitary
- sewer,Storm serer,Tigard water
Contractor. and/or Tigard Water Service Area
Ir
CCB#: 11; Expira 'on: v{� SMUT corenarrircAT►oivTO:
Address: , City of Tigard
City/state: i' Zip: Plsmring/EagiweTing
Ph on t_7Z or ma pfj, r 13125 SW Hatt Blvd.
_ Tigard,OR 97273
Contact name: — Phon r, Applications for"minor work in nghr-of-way"
only mac be emailed m:
Engineer: v tc'� ggO4
Address:
City-/state: Zip:
Phone: Email: Case Na: PF12022-00062
Contact name: Application submittal fee:
Additional fees:
1�
Estimated value of work is required(if ova S5,000): Application acceprtd:
(within the public right of-way) Bv: HPollard Date. 2/22/2022
Is work related ur a LAIND-USE DECISION? D 'res 1Sd-No Application reviewed:� , f X Dam 212-ilea–)2
If so, please specify (' ILP,SDR, SUB,etc.) case #: 13Y
Apphcant nonfied:
Is work related to a BUILDING PERI IP ❑ YesC�1`o By:
If so,please specifi•(BUILDING PERMIT)case#: IAMMOAr+.ss eVA de Amkm a. o';oa ni
City of Tigard - 13125 S`Y'I3a11 Bhp • Tigard,Omgcin 97223 a wwvuigard-or$ov • 503-718-2421 • Page 1 of 4
APPLICANTS
NOTE: Person specified as"Applicant"shall be designated "Permittee"and shall provide financial assurance for work.
•When the owner and tate applicant ate different peopk,the applicant must be the purchaser of record or a lessee in possession with written
aurbotintion from the owner or an agent of the owner. The owner(s)must sign this application in the space provided or submit a written
auaimtizarim with this application
BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT:
• The aboc raWcst does not violate=deed restrictions thar tout,,be attached to or imposed upon the s t 'ret nrotxrtr.
• If the application is granted,the applicant w771 exercise tate rights granted in accordance with the terms and subject to ail the
conditions and limitations of the approval.
• All of the above statements and the statements in tate plot plan,attachments,and exhibits transmitted hcrearith,are true;and
the applicants so acknowledge that any permit issued,based on this application,may be rooked if it is found that any such
statements arc false.
• The applicant has read die entire cantatts of the application,including the policies and criteria,and understands the
requirements for approving or denying the application.
SIGNAVURES of ggch owner of the subject property required.
I 1 �t,dda iL6 ,r
Appli2tit's signature Print name t Date
Owner's si&ature Print�kame hate
Owner's signature Print name Date
C?wnds signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tign+d - 13125 SCC"Hall Blvd. • Tigard,Oregon 97223 - wwwtipardor.gov 503-718-2421 • Page 2 of 4
DocuSign Envelope ID:OB5CA18B-C489-42B7-8226-A5F0539FSD9A
� idewalk EST NO.
epair PROPOSAL
pecialist
- - :--walkrepa!rs@grana".._.. P�cne: 503-707.0'..
CCB# 198613 - : www.s eewalkreDa > -__
Eliminate Trip Hazards
Property owners are responsible for the repair and maintenance of the sidewalks adjacent to their property.Avoid the costs,dangers
and hassles of being involved in a trip hazard lawsuit for personal injury.Your neighbors, children on bicycles or skateboards, new
mothers with baby carriages,disabled people in wheelchairs and everyone else have one common need:A smooth,safe sidewalk.
Let our experienced professionals grind out trip hazards or replace sidewalk sections as needed.
Customer (�
Name: Nl l c he! F L lir {-jU p, ( 15000
Address: (Q1caC) .5W---3 kw_lwter_' LA
Ti r �
Phone. Email: yyl(GhtI�C �dr'en QrS, YL - __.,_ W
Personalized Estimateaa !
0Grinding Subtotats
EA
Areas: Est. L. Ft.: I'^
t I. I,•.
Other:
L
A
Q Sidewalk Replacement Fe 4L Le 1�
Areas: Est. L. Ft.: g Est. ✓r (P a �1
JC
u /1
Other: A
_ I - Per "N- - TI 1.1 afd
Grinding NO TRAFFIC IMPACT NO VEHICLES ON
Sidewalk Replacement SIDEWALK CLOSED A _ Scholls Ferry Rd
Warranty "USE OTHER SIDE" isigns) All work vehicles
Cont7actorwar'anCS mater' gnO v.OrK^ahSh'D'C Di?'Z�C 6;1 yea" a PMy" cC"I:000 i 'd oCCuiS Jd J e c'F a`.
Disdalaw Use Summerlake Dr
--Nevl7 g'OLnd co-�c-ete and nemy reoaced concrete wi l have a different amea•a-ce!,,a,jamr e.st y conc-ete esee. •wr ?
Cdb-OC f'e5:;"^5 r�h:fe SOi mOVeTenC fro^•`rPe roots Other CO!ly-C'D'15 Dey`Ond pV CO'VO e 57rT�'e'S.d'dn'+nes .at)P'.'le'
Acceptance of Proposal
The d"02':?D �: '__ ?'^_ - _ C'15 d "a'2'-. 3:cepte"..S'dewa'r Reva-Soevalist s-lereoy autnonzed to perform the work a5
pa'y ailcosu"D'Ca,e:t'h iC!ud;'g:ou't COSt5a)''Pca'rmr.
, — ned DY
ocu ip
2/17/2022
Buyer Signature: Date:
Contractor Signature: Date:
- - -- INITIAL HERE:
2/22122,8:45 AM "2598 SW Scholls Ferry Rd-Google Maps
Go---gle Maps
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All Street View& 360° ^ Q � L e
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2/22/22,8:40 AM 10600 SW Summer Lake Dr-Google Maps
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Ace` CERTIFICATE OF LIABILITY INSURANCE DATE(MMVDDM YYI
121712021
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endomement(s).
PRODUCER CI1NAME Rachel Sandwick
Rachel Sandwick �,s"r;a E,�. (503)256-1448 FA" 503 256-5825
78315 EChamberlain Insurance Agency LLC E p�8 , h I Cham rl I in an R)
7831 SE Stark St#102
Portland,OR 97215 INWRE S AFFORDIN_GCOVERAGE M110/
RBLRERA_Contractors Bondi &Ins Co 37206-
INSURED INSURER B: ---- - __
Jay Jacob Miller INSURER D.
INSURER D: -----
NSURER E:
iNS
COVERAGES CERTIFICATE NUMBER: 2852 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ! POLICY EFF '-POUOY EXP ..
LTR' PO YN LIMITS
A X COMMERCIAL GENERAL LIABILITY j 1 ID11PJ6671 1 12/12/21 12/121221uu+01-cURRENCE 61,000,000
X CLAIMS-MADE % OCCUR SII PREMISES(Esgtc n 1100,000
MED EXP(Any one fewness) $5,000
PERBONAL6_ADVINJURY 11,000,000
GENT AGGREGATE WAR APPLIES PER: GENERAL 12,000,000
X POLICY I ECT C LOC PRODUCTS-COMP1o,AGG 12,000,000
I
AUTOMOIN E LL#AA Y BINEC II E LIMIT 1
aO:idtM
ANY AUTO .BODILY INJURY(Per person) S
OWNED SCHEDULED
AUTOS ONLAUTOS BODILY INJURY(Pmacade(t) /
HIREDY
AUTO NOWAUTOS
PERTY DAMAGE 1
AUTOS ONLY AUT080NLY Per aga:,dsM
f
UMBRELLA LIASOCCUR EACM OCCURRENCE I
EXCES$LL48 _ (C_W_M&MADE AGGREGATE 1
DEO RETE NTIDN S I
WORKERS COMPENSATION PER STATUTE O
AND EMPLOYERS'LULBeITY YIN
ANY PROPRIETORRARTNER'EXECUTIVE I EL EACH ACCIDENT 1111
ornCERIMEMSER EXCld1DED� ® NIA
LManslatary In Na!) ILL DISEASE-EA EMPLOYE I
eyyeast deeCiMt.mder
DESCRIPTON OF OPERATIONS psI E.L.DISEASE-POLICY LIMB s
I
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD iOl,Additional Ram Ms Schedule,may W attached d mot space is required)
CERTIFICATE HOLDER CANCELLATION
Ir�rlrrrlrrrrllrrrrrlllllrllrrrrlrllr/Irrrrrrrrllllrlrllllrrrrrl SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATON DATE THEREOF, NOTICE WILL RE DELIVERED IN
u�uiumnumnrnnn�u�uiuiumnu»imnuumur ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
1 �
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