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PFI2014-00113 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT ,1 COMMUNITY DEVELOPMENT Permit#: PF12014-00113 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 11/19/2014 Parcel: 2S103DA04200 Jurisdiction: Tigard Site address: 10690 SW PARK ST Subdivision: FANTASY HILL Lot: 5 Project: Rosenquist Storm Connection Project Description: Adjacent to 10690 SW Park Street. Connect gutter drains to storm drain. Owner: FEES Description Date Amount PHONE: Contractor: PHONE: FAX: Applicant: KATHLEEN ROSENQUIST 10690 SW PARK STREET TIGARD,OR 97223 PHONE: 503-620-2721 Total 50.00 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: 'C°SY , n Dnr Issued By: AAM Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12014-00113 Type: Condition Name: Status: Severity: PFI—Sidewalk/1 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/1 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/1 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/1 05-PRECONSTRUCTION MEETING Applied Notice Before initiating any construction activity,the applicant shall coordinate with the City's inspector, <Insert Name>at<Insert Phone#>, to establish a preconstruction meeting. PFI_Sidewalk/[ 06-NOTICE TO COMMENCE WORK Applied Notice The applicant shall notify the City's Inspector Kenny Fisher at 503-816-6146 or email at kenny@tigard-or.gov twenty-four (24)hours prior to commencing work, prior to any staged inspection, and after completing work covered by the permit. PFI_Sidewalk/[ 07-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/[ 08-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/[ 09-OTHER Applied Notice RECEIVED City of Tigard N O V 13 2014 PUBLIC WORKS — ENGINEERING CITY OF TIGARD . . , (PFV'_'r"e' _rrilNEERING Public Facility Improvementt DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL Check one: ❑ Utilities X Sidewalk-/driveway approach ❑ Street improvements ELEMENTS Detailed description: 60 f1 iU-(—f J&J.JL h� d-.4, ❑ Mmor work in right-of-way N Q�' (sidewalk repair,curb cut,street d"41 opening,etc.)requires: •Application form,completed and signed n •Submit one(1)copy of scaled sketch Property address/location(s): D ` lq ,�.k of the proposed work to be done �— �� D •Submit one(1)copy of traffic control plan OR- Ap plicant's /out �,5-ew%,u-" S ❑ Substantial project work requires Applicants name: l�/to �Q above items and professional Address: /�&1 ;5;to / a k k S-f• engineered plans for. /state: `T G{'L� •Street widening City 1 Zip: �� •Subdivision infrastructure PhoW?3—(0-_q)-a791 Email: O 5ko a tL(� Oyl-{tQ_r •Main utility line extension: t✓t y - Storm Drain,Sanitary—Tigard / Water—Tigard Water Service Contractor's name: Q r r t f kos P �c�tic JV Y "� Area(includes Durham,king City nn — CCB#: '/ 7 L 'L O Expiration: / and a portion of unincorporated Address: /411 5 5 L e j a c� " Washington County) /� J DELIVER APPLICATION TO: City/state: Qr�1�� Citi-1 C) K_ Zip: 9 70 4 City of Tigard Phone: - b_ 3&0 r mail: Planning/Engineering 13125 SW Hall Blvd. Engineer's name: Tigard,OR 97223 10 V Applications for"minor work in right-of-way" Address: only may be emailed to: City/state: Zip: Phone: Email: Case No.: 12L�1�}-00113 Estimated value of work (within the public right-of-way): $ _0 . Application submittal fee: Is work related to a LAND-USE DECISION? ❑ Yes ` No Application accepted: If so,please specify (MI.P, SDR,SUB, etc.) case #: By:&I9f- Date: 11 Is work related to a BUILDING PERMIT? XYesb No Application reviewed: If so,please specify(BUILDING PERMIT)case#: By:,f Date: I/ 8� Applicant notified: By: 163L Date: i:\cuevurW+.•eersu.na Use AaWwtlo". City of Tigard 13125 SW Hall Blvd. - Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page I of 4 APPLICANTS NOTE: Person specified as"Applicant" shall be designated"Permittee"and shall provide financial assurance for work. *NX7nen the owner and the applicant are different people,the applicant must be the pmdnaser of record or a lessee in possession with written authorization from the owner or an agent of the owner. Tlx owner(s)must sign this application in the space provided or submit a written authorization with this application. BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT: • The above request does not violate ny deed restrictions a may be attached to or imbed upon the subject props • 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 the 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. SIGNATURES of each owner of the subject property required. Applicant/Authorize Lt sig re Print name Date L Owners signature Print name Date Owners signature Print name Date Owners 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 ■ ■ � �� ■ ■�� ■� �1 �� +1'�r:� �� • • � I, ---- �� ■� � 'C .... .. � � � .�� .