PFI2015-00146 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12015-00146
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 10/15/2015
Parcel: SEG1937, 1940, 2076
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Rose City Concrete
Project Description: Adjacent to 10695 SW Murdock St. Removing&replacing sidewalk around Pacific Crest Apartments.
Owner: FEES
Description Date Amount
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
MELISSA WINTER
3300 NE 185TH,#183
PORTLAND, OR 97229
PHONE: 503-292-9702
Total $0.00
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
e�
Signature:
Issued By: VIL 0 /��� j 1 l o d aov A (Nr &I �rZ7� C v
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12015-00146
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/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/[ 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/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
City of "Tigard
p PUBLIC WORKS — ENGINEERING EIFCEIVED
• Improvement (PFI) tPublic Fac�ty mp 6F 15
DESCRIPTION OF WORK (in the right-of-way) 'IPAMWWOMNEERING
Check one: ❑ Utility Connection ❑ TYPE 1-Franchise Utility Work
Sidewalk/driveway approach Work performed by N1VT,1'Gl:
r
❑ Street improvements and/or utility agency.
Detail---' description: c 1 C,' *TYPE 2-Sidewalk/Driveway/Sewer
�" " Work performed for the purpose of:
^i Sidewalk installation or repair.
l�i71 ?T, Driveway approach installation
and/or repair
Property address/location(s): j��5C:_V
^h • Sanitary sewer lateral installation
o(v and/or main line tap
❑ TYPE 3-Full scale Development
Applicant
<< �' Work performed with Land use
-
• ,.-�
approval which includes any of
Address: n the following-
sl
ollowing
/sl te: _ Zip: Subdivisions or Partitions
n . C ,� Email: t ;S Street widening
c
7C/ 7_ �� U I 1 • Mainline installation for Sanitary
Contact name: _ Phone: .•
sewer,Storm sewer,Tigard water
Contractor:
r
50 Ij and/or Tigard XMtter Service Area
CCB#: 4S14-1-7,;— Expiration: 2 ZIIIL,, SUBMIT COMPI.ETEDMPLICATIONTO:
Address: %,I, � 1 City of Tigard
City/state: 1 ' r Zip: `l]a?�`7' Planning/Engineering
13125 SW Hall Blvd.
P : a14 1- q70 Email: " ' �m ti - Tigard,OR 97223
Contact name: P > 2q v' AVX Applications for"minor work in aglit-of-way"
i only may be emailed to:
1/ ./I
�g�ermitsCa dgard-or.Qov
Engineer: l /t
Address:
City/state: Zip:
Phone: Email: Case No.: ,Awcy S-- co (�
Contact name: Application submittal fee:
Additional fees:
Estimated value of work is required(if over$5,000):$ 1 J LCy Application accepted:
(within the public right-of-way) By �j Date: 5
Applicata n reviewed:
Is work related to a LAND-USE DECISION? ❑ Yes � No By:.-YR Date: 10, 1 S (S
If so, please specify (MLI,SDR,SUB, etc.) case #:
Applicant notified.
Is work related to a BUILDING PFRMIT? ❑ Yes `0 No
B /�M 1 b Date: l�/�I-1/S
If so,please specify(BUILDING PERMIT)case#: 1.\rua"tM•stemu•ndcs.ApOicadms "••.07roWn015
City of Tigard •/13125 SW Hall Blvd. • Tigard,Oregon 97223 wwwtigard-or.gov • 503-718-2421 • Page 1 of 4
S.1�eW A llI► ,,, e 0,,"0-
APPLICANTS
NOTE: Person specified as"_\pplicant" shall be designated "Permittee"and shall provide financial assurance for work.
\C'hen 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 ovtner(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 maybe attached to or imposed upon the subject tn�ertr.
• If the application is granted, the applicant will exercise the rights granted hit accordance with the terms and subject to all the
conditions and limitations of the approval.
• All of the above statements and the statements vh 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 denyuig the application.
SIGNIIRES of owner o subject property required.
Applicant/ prized ge is signature Print name Date
Owners signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
�x�-ter'-a ••.. ... _. c;e^: -�.;.:. .°,...;...,.�._ Fb:.ic---.�.m��, a:.a->:<_�M;�y^'�..�-=��.�i�; ..-: -�- �s:�..,,:::.�*M
PUBLIC FACILITY IMPROVEMENT PERMIT
Cityof Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 972293 • www.tigard-or.gov 503-718-2421 • Page 2 of 4
zc
RECEIVED
OCT 12 2015
CITY OF TIGARD
PLANNING/ENGINEERING