PFI2015-00088 u CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12015-00088
. f 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 06/25/2015
Parcel: 2S111AD05000
Jurisdiction: Tigard
Site address: 8870 SW PINEBROOK ST
Subdivision: PINEBROOK TERRACE Lot: 73
Project: Driveway plus the approach
Project Description: Driveway plus the approach
Owner: FEES
Description Date Amount
PFI Permit Fee 06/25/2015 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
TYSON KREBS
8870 PINEBROOK
TIGARD,OR 97224
PHONE: 503-467-9902
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 (:::)V�_4�
Signature:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12015-00088
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/[ 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/1 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_SidewalkA 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
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City of Tigard RECEIVED
_ PUBLIC WORKS — ENGINEERING JUN 2 3 2015
Public Facility Improvement (PF
VN GAF RlniL
DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL
Check one: ❑ Utilities A Sidewalk/driveway approach ❑ Street improvements ELEMENTS
Detailed description: ❑ Minor work in right-of-way
(sidewalk repair,curb cut,street
r I U�IAJCJ�1lV ft S t �+C Pro a �t opening,etc)requires:
•Application form,completed
and signed
•Submit one(1)copy of scaled sketch
Property address/locadon(s): �� 5W �l»br )k of the proposed work to be done
• Submit one(1)copy of traffic
- Q,r control plan
–OR–
I ElSubstantial project work requires
Applicant's name: - h r--e b above items and professional
Address: G fal pytLhfOo e DE engineered plans for:
1 - •Street widening
City/state: T-0152 Yr I 02 Zip: Z •Subdivision infrastructure
Phone: - D mail:�ie�B$, TVSow Qyy1�l •Main utility line extension:
Storm Drain,Sanitary-Tigard
- Water-Tigard Water Service
Contractor's name: Area(includes Durham,King City
CCB#: Expiration: and a portion of unincorporated
Washington County)
Address: _
City/state: p: DELIVER APPLICATION TO:
City of Tigard
Phone: Email: Planning/Engineering
13125 SW Hall Blvd.
Engineer's name: Tigard,OR 97223
Applications for"minor work in right-of-way"
Address: only may be emailed to:
City/state: Zip: rownermits(ktigard-or.Qov
Phone: Email:
FOR ONLY
Q
Case No.: 1 2.0 l 5- `0 Go 88
Estimated value of work (within the public right-of-way): $ Application submittal fee: 1306 -00
Is work related to a LAND-USE DECISION? ❑ Yes ❑ No Application accepted:
If so,please specify (MLP,SDR,SUB,etc.) case #: By: Date: L3 5
Is work related to a BUILDING PERMIT? ❑ Yes ❑ No Application reviewed:
If so,please specify(BUILDING PERMIT)case#: By: Date: (P
Applicant notified:
By: Date:
1:\CURPLN\Masters\Land Use Applications Rev.07/16/2014
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 www.tigard-or.gov • 503-718-2421 • Page I of4l
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 does not violate any deed restrictions ha may be attached to or imposed upon the subico )rop cr ).
• 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.
App is t/Authorized Agent's signature Print Mame Datc
Owner' signature Print ame Date
Owners signature Print name Date
Owner's 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
Y
DEVELOPMENT ENGINEERING FEES
1. Public Facility Improvement(PFI)Permit:
Part 1: Required submittal fee$300.00
Part 2: All non-water system improvements
Engineer's estimate X 5%(less$300.00 submittal fee)
Engineer's estimate X 2%Plan Review
Part 3: All public water system improvements
Engineer's estimate X 12%
Total Permit Fee=Part 2+Part 3
PFI Permit Fee Exemptions:
There will be no permit fee charged,or assurance required for the following types of work:
• Sidewalk or driveway repair(less than 20 lineal feet)
• Relocate or replace mailbox
• Ditch cleaning that does not involve regrading.
• Weephole repair
• Curb repair or replacement(less than 20 lineal feet)
• Lawn sprinkler system installation or repair
• Street tree pruning or planting
• Planter strip landscape maintenance
• Test wells
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2421 Page 3 of 4
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SAMPLE SKETCH: 0
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Scale: 1"=30'
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MINIMUM SKETCH REQUIREMENTS (Put"N/A" if Not Applicable):
North arrow Property lines&dimension Slope of property
Street&street name(s) Existing building,structures Utility&street light poles
Proposed work Existing curb or edge Trees
Existing S/W or of pavement Existing utility locations
D/W apron (sewer,water,storm)
PUBLIC FACILITY IMPROVEMENT PERMIT
Cityof Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 4 of 4