PFI2015-00140 q CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12015-00140
13125 SW Date Issued: 10/12/2015 Hall Blvd ,Tigard OR 97223 503 718 2421 Parcel: 2S111AB03300
Jurisdiction: Tigard
Site address: 9430 SW MCDONALD ST
Subdivision: ELROSE TERRACE Lot: 27
Project: 9430 McDonald PFI
Project Description: Install 2 sanitary sewer lines and 2 water lines along the flag pole recently created via a lot line
adjustment
Owner: FEES
Description Date Amount
PFI Permit Fee 10/12/2015 $56000
PHONE Customer Deposit 10/12/2015 $8,00000
Contractor:
PHONE
FAX
Applicant:
THOMAS FRENI
9430 SW MCDONALD ST
TIGARD, OR
PHONE 503-314-5893
Total $8,56000
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
i
Permittee/Applicant
Signature:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
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City of Tigard
November 19, 2015
Thomas &Tracie Lynn Freni
9430 SW McDonald St.
Tigard, OR 97223
Re: Permit No. PFI2015-00140
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 9430 SW McDonald St
Project Name: Freni
Job No.: N/A
Refund Method: ® Check#219205 in the amount of$8,560.00.
❑ Credit card"return" receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account "deposit" receipt in the amount of$
Comment(s): Permit was not required per engineering technician. Refund 100% of
permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. e Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
i
City of Tigard
M-A Accela Refund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and d-ie Reque.it forPeinzit�4etion form (if applicable) must
be attached to this request form. Refund requests are due to Accela System Administrator by
each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: Thomas &Tracie Lynne Freni DATE: 11/06/20-15
9430 SW McDonald St.
Tigard, OR 97223 REQUESTED BY: Dianna Howse
AD
TRANSACTION INFORMATION:
Receipt #: 400070 Case #: PFI2015-00140
Date: 10/12/2013 address/Parcel: 9430 S%-V'TMcDonald St
Pay Method: Check Project Name: Freni
EXPLANATION: Permit not required per engineering staff,—1 Dickman. Refund 100% of permit fees.
.. i
.REFUNDI NFORb1ATION:,.t+ -
•- zz
-Fee Descri tion From Recei t - -. ,r.;
NY
pti p, _,_: Revenue Acc 'Refiirid'
.EYam le::Buildin,.Permit Fee Elam le 2300000'43104 : x$Amount..;"
Customer Deposit 100-0000-22000 $8,000.00
PFI Permit Fee 100-0000-43114 560.00
TOTAL REFUND: $8,560.00
APPROVALS: SIGNATURES/DATE:
If under$3,000 Professional Staff ---
If under$12,500 Division Manager
If under$25,500 Department iManager
If under$30,000 City Manager
If over$50,000 Local Contract Review Board
TIDEMARKSYSTEM ADMINISTRATION USE
Case Refund Processed: I Date: By:
1:\Building\Refunds\RefundRequesc.doc x 09/01/2010
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City of Tigard • c.(mimuNrn Di:A 1cI.c�Pnu:Nr DI:P.ARr:\I�:N '
Request for Permit Action
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 S\\/I-Iall Blvd.,I'igard, OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPernuts@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff".
Check(✓)one
REFUND OR Name:
INVOICE TO: (19usiness:,r Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #:
Site Address or Parcel #:
Pro)ect Name: � ��
Subdivision Name: Lot#:
EX LANAT ON:
Signature: Date:
Print Name: -
Refund Police
L '191e die's ConunLill ity Development Director,Building()fficial or City I?nginecr may authorize the refund of.
• iAnc fee which was crrona:uslc paid or collected
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued Permits prior to ally inspection requests.
2. All refunds will be returned to the original pziccr in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
e ' e ONLY,
Route to Sq,,;_Admin. Date Bt- Route to Records: Date e5 / B7
Refund Processed: Dare// lar Invoice Processed: Date I3v
Permit Canceled: Date 13�- ?atcel Tag_Added: Date B�
I:ABuddurg\14>nns\RcyPcrnutr\ction_U'._314. uc
Conditions for PF12015-00140
Type: Condition Name: Status: Severity:
PFI—Utilities 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—Utilities 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—Utilities 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—Utilities 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—Utilities 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—Utilities 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—Utilities 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_Utilities 08-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—Utilities 09-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_Utilities 10-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_Utilities 11 -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_Utilities 12-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—Utilities 13-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 Utilities 14-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_Utilities 15-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_Utilities 16-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—Utilities 17-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—Utilities 18-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_Utilities 19-MONUMENT PROTECTION Applied Notice
Existing monuments, property corners, and survey markers shall be protected Replacement shall be at the permit holder's
expense.
PFI_Utilities 20-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—Utilities 21 -OTHER Applied Notice
PROJECT NO. FRE002
Lo
I s DATE: 10/5/15
BY: TWB
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TAX LOT 3200 I ( NO N 0
DOCUMENT NO. 2007-02681
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LEGEND
-- -- — EXISTING BOUNDARY
-- -- — ADJUSTED PROPERTY LINE
-- -- — EXISTING PROPERTY LINE SHEET NO.
— — EXISTING CENTERLINE
— EXISTING BUILDING
— EXISTING CONCRETE i
w w — PROPOSED WATER LINE I
ss ss — PROPOSED SEWER LINE
SCALE: 1"=40'
City of Tigard RECEIVED
PUBLIC WORKS—ENGINEERING OCT 0 5 2015
Public Facility Improvement (PFI) Per
TIGARD
DESCRIPTION OF WORK(in the tight-of-way) TYPE OF WORK
Check one: Utility Connection ❑ TYPE 1—Franchise Utility Work
❑ Sidewalk/driveway approach Work performed by NWN,PGE
❑ Street improvements and/or utility agency.
Detailed description: The applicant is proposing to XTYPE 2—Sidewalk/Driveway/Sewer
install 2 sanitary sewer lines and 2 water Work performed for the purpose of:
lines along a flag pole recently created via a • Sidewalk installation or repair.
lot line adjustment • Driveway approach installation
Property address/location(s): and/or repair
9430 SW McDonald Street (flag pole is located ' Sanitary sewer lateral installation
off of SW 93rd Avenue. and/or main line tap
❑ TYPE 3—Full scale Development
Applicant: Thomas and Tracie Freni Work performed with Land use
Address: 9430 SW McDonald Street approval which includes any of
Tigard, Oregon 97224 the following:
City/state: g g Zip: • Subdivisions or Partitions
Phone: 503 . 314 . 5 8 9 3 Email: • Street widening
Contact name: Tracie Freni Phone: 503 .314 . 5893 • Mainline installation for Sanitary
sewer,Storm sewer,Tigard water
Contract r: Tryon Creek Landscape and/or Tigard Water Service Area
CCB#: 5 8 0 2 Expiration: 3/16/2017 SUBMIT_ p MIT COMPLETED APPLICATION TO:
Address: 11400 SW North Dakota Street
City of Tigard
City/state: Tigard, Oregon Zip: 97223 Planning/Engineering
5 0 3 . 6 2 4 .217 4 13125 SW Hall Blvd.
Phone: Email:
Stacey Werner 503 .209 . 6909 Tigard,OR 97223
Contact name: Y Phone: Applications for"minor work in right-of-way"
only may be emailed to:
Engineer: SR Design LLC ro"ermits&tiga_ rid-or.gov
Address: 8196 SW Hall Blvd. , Suite 101
City/state: Beaverton, Oregon Zip: 97008
FOR STAFF USE ONLY
Phone:5 0 3 .4 6 9 . 1213 Em2dl:melindag@srdllc.com Case No.; 1 ` 10 15 - t?0 144 0
Contact name: melindag@srdllc.com Application submittal fee: 9W
Additional fees: i7_0000 -c ark ASd icrc:
Estimated value of work is required(if over$5,000):$ Application accepted: /
(within the public right-of-way) r • � By: �n Date: 1'0/ S/)S
Is work related to a LAND-USE DECISION? ElYes No Application reviewed:
By: Date:
If so,please specify (MLP, SDR, SUB,etc.) case #:
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes X No By: Date: �b ' 1a _ts
If so,please specify(BUILDING PERMIT)case#: l:\CURPLN\Masters\Land Use Applications Rev.07/09/2015
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.dgard-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 th1s application in the space provided or submit a written
authorization with this apphcation
BY SIGNING BELOW, THE APPLICANT(S) SHALL CERTIFY THAT:
• The above request does not violate any deed restrictions that may be attached to or unposed upon the subject proper.
• 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.
Apphcant/Authorized Agent's signature Print name Date
Owner's signatures
Print name 6ale
Owner's signature Print name Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 2 of 4