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PFI2015-00056 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT � O s COMMUNITY DEVELOPMENT Permit#: PF12015-00056 i 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 04/29/2015 Parcel: 2S103DD03200 Jurisdiction: TIGARD Site address: 10830 SW GARDEN PARK PL A Subdivision: GAARDE PARK Lot: 15 Project: loanide Project Description: Replace 35'of sidewalk. Owner: FEES Description Date Amount PFI Permit Fee 04/29/2015 $300.00 PHONE: Contractor: WESTERN OREGON BUILDERS PO BOX 90220 PORTLAND, OR 97290 PHONE: 503-381-5708 FAX: Applicant: BEATE IOANIDE-CULT 70 NE FREMONT ST. PORTLAND, OR 97212 PHONE: 503-380-2714 Tota 1 $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 Signature: Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12015-00056 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/1 09-OTHER Applied Notice City of Tigard 44 PUBLIC %X'ORKS —ENGINEERING Public Facility Improvement (PFI) Permit DESCRIPTION OF WORK(in the right-of-way) SUBMITTAL Check one: El Sidewalk/driveway approach El Street improvements ELEMENTS Detailed description: 2E.QUIRED . r work in right-of-wav (sidewalk repair,curb cut,street opening,etc.)requires: •Application form,completed and signed •Submit one(1)copy of scaled sketch Property address/location(s): of the proposed work to be done 'Submit one(1)copy of traffic W 11 f control plan OR— El name: lotlDe— W U ❑ Substantial project work requires PP above items and professional Address: rF4,-J"tio0ir ST• engineered plans for: •Street widening City/state: ��7ZJ� f� �¢ Zip: �72)2 •Subdivision infrastructure Phone: 1+Email: 12!Ae eE f K b&� k•O •Alain utility line extension: A LEX 0.441 l�E - Storm Drain,Sanitary—Tigard �� V) �,�� - �`�ater—Tigard Water Service Contractors name: �VG`��i�1� Area(includes Durham,King City CCB#: Expiration: and a portion of unincorporated Address: D g✓Dx 0 220 Washington County) � !70¢R�`Q� ©� Zi -72� DELIVER APPLICATION TO: City/state: Zip: City of Tigard Phone:a3' -S1016 Email: Planning/Engineering 13125 SW Hall Blvd. Engineer's name: Tigard,OR 97223 Appfications for"minor work in right-of-way" Address: only may be emailed to: City/state: Zip: tQ=ermiits Rtigarrd-or.gov Phone: Email: FOR STAFF USE ONLY Case No.: P 2Q1. ` Estimated value of work (within the public right-of-way): $ Application submittal fee: Is work related to a LAND-USE DECISION? ❑ Yes X No Applic�V_ cented: If so,please specify (INILP, SDR, SUB, etc.) case #: By:--- Date: Is work related to a BUILDING PERbIIT? El Yes reviewed: Yes No Q If so,please specify(BUILDING PERMIT)case#: Bv: K-*' Date: :applicant notified: By: Date: 1:\CURPIN\Masters\land Use Applications Rev.07/16/2014 City of Tigard • 13125 S\vv'Hall Blvd. • Tigard,Oregon 97223 • ww-w.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 APPLICANT(S) SHALL CERTIFY THAT: • The above request does not violate any deed restrictions that may be attached to or imposed upon the subject property. • 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/Authorized Agent's signature Print name Date Owner's signature Print name Date Owner's signature Print name Date Owners signature Print name Date PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • ww-w:tigard-or.gov • 503-718-2421 • Page 2 of 4