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PFI2015-00001 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT 4 COMMUNITY DEVELOPMENT Permit#: PF12015-00001 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 01/08/2015 Parcel: 1 S134BD07006 .jurisdiction: Tigard Site address: 11360 SW COTTONWOOD LN Subdivision: ENGLEWOOD NO.3 Lot: 231 Project: Ramer Project Description: Remove and replace 22'x8'driveway approach. Owner: FEES Description Date Amount PFI Permit Fee 01/08/2015 5300.00 PHONE: Contractor: CUSTOM CONCRETE CONSTRUCTION 4510 SW POPLAR LN. PORTLAND, OR 97225 PHONE: 503-628-4505 FAX: Applicant: MURRAY LEISrvIEISTER 4510 SW POPLAR LN. PORTLAND, OR 97225 PHONE: 503-628-4505 Total $300.00 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 �'� i�r^ �1� Signature: Issued By: Y, y �J, � Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12015-00001 Type: 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-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 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 City of Tigard PUBLIC WORKS — ENGINEERING Public Facility Improvement (PFI) Permit DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL Check one: ❑ Utilities [,Sidewalk/driveway approach ❑ Street improvements ELEMENTS n right-of-way Q� Minor work it-of--way Detailed description: URB-C-42: Apa9�� , . (sidewalk repair,curb cut,street opening,etc.)requires: •Application form,completed and signed •Submit one(1)copy of scaled sketch PLopgty address/location(s): 113�O SW c jft- 12;p LJN) of the proposed work to be done •Submit one(1)copy of traffic control plan —OR— Applicant's name: mj�, � S �sl ❑ Substantial project wort:requires above items and professional Address: engineered plans for: •Street widening City/state: Zip: •Subdivision infrastructure Phone: Email: •Main utility line extension: - Storm Drain,Sanitary—Tigard r - eater—Tigard Water Service Contractors name: C, jt0m CPHC&_Z� CVNC Area(includes Durham,King Cit} CCB#: 19WQ3 Expiration: and a portion of unincorporated Address: `1;,L`2 5W DQJ9e / Washington County) ��' (.�J N City/state: 1'lJf 2\ A r� Zip: DELIVER APPLICATION TO: City of Tigard Phone:%;?,- w40\2W Planning/Engineering (n'(pQ' wc� C'�5Wn-cam -coN5 V ,C 13125 SW Hall Blvd. Engineers name: m�l`�•G CM fCrTJ5 P 7 W �l)m Tigard,OR 97223 Applications for"minor work in riglit-of--way" Address: only may be emailed to: City/state: Zip: r�'per""ts(g�ti-- d-0r� Phone: Email: Case No: P 1:71210 1 S `0" ` Estimated value of work (within the public right-of-way): $ ?J�,00 Application ubmittal fee: Is work related to a LAND-USE DECISION? ❑ Yes 29 No App accepted: C If so,please specify (MLP, SDR,SUB,etc.) case #: By Date: Application reviewed: Is work related to a BUILDING PERMIT? El Yes I No If so,please specify(BUILDING PERMIT)case#: By: Date: Applicant notified: By: Date: e\cuevuNMnanwmw Use Aovac.n no wK 07/1e/2M City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • vwvw.tigard-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. *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. BY SIGNING BELOW,THE APPLICANTS) SHALL CERTIFY THAT: • The above request dos not violate my deed restrictions that may be attached to or im�nosed ua n the subject pronert;. • 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 owner of the subject property required. A'��-AIA cant/ ed Agent's signature Print name Date 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 Bbd. • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2421 • Page 2 of 4 11�� Y1� (�D{►dl�� LP) , l CITY OF TIGARD RECEIPT 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 Receipt Number: 198943 - 01/08/2015 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12015-00001 PFI Permit Fee 100-0000-43114 $300.00 Total: $300.00 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 00118B TLEHRBACH 01/08/2015 $300.00 Payor: Murray L Leismeister Total Payments: $300.00 Balance Due: $0.00 Page 1 of 1