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PFI2015-00160 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12015-00160 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 10/28/2015 Parcel: 2S 104AB04100 Jurisdiction: Tigard Site address: 13336 SW SCOTTS BRIDGE DR Subdivision: MORNING HILL NO.3 Lot: 74 Project: Sidewalk PFI 13336 SW Scotts Bridge Dr Project Description: Remove and Replace 17x5 ft section of Sidewalk at 13336 SW Scotts Bridge Dr. Owner: FEES Description Date Amount PHONE: Contractor: PHONE: FAX: Applicant: LEX LEX 12070 SW FISCHER RD TIGARD, OR 97223 PHONE: 503-810-3752 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 r ` Signature: Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12015-00160 imL 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/1 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_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 � I RECEIVED City of Tigard OCT 27 2015 PUBLIC WORKS— ENGINEERING CIT`!OF TiGARD Public FacilityImprovement �' Termit DESCRIPTION OF WORK(in the right-of-way) TYPE OF WORK Check one: ❑ Utility Connection ❑ TYPE 1—Franchise Utility Work Sidew riveway approach Work performed by NWN,PGE ❑ Street improvemen s and/or utilityagency. Detailed description: tf'ILiJJ ct c 1S TYPE 2—Sidewalk/Driveway/Sewer 1-7X C2 C::L �j �� " � Work performed for the purpose of- Sidewalk- £Sidewalk installation or repair. Driveway approach installation Property address/location(s): 37 J S w `� and/or repair n 2 ' 7'L 12 f Sanitary sewer lateral installation �� and/or main line tap ❑ TYPE 3—Full scale Development Applicant: Work performed with Land use approval which includes any of Address: the following- City/state: ollowingCity/state: Zip: • Subdivisions or Partitions Phone: Email: • Street widening Contact name: Phone: • Mainline installation for Sanitary sewer,Storm sewer,Tigard water Contractor: reA*tv t and/or Tigard Water Service Area CCB#: / r7 3�J Expiration: SUBauT COWILMM A"UCATIoN TO. Address: &076 '010 - d City of Tigard City/state: '774e,<4 Zip: 2 Z Planning/Engineering Phone: J` Jail: pl�?_ Jy'trG f t�Mxycrig(C 13125 SW Hall Blvd. _meq Tigard,OR 97223 Contact name: �- Phone: p- Applications for"minor work in right of--wap" only may be emailed to: Engineer: rowoermrts aC d9Md Address: City/state: Zip: p Phone: Email: Case No.: I F 1 2015 -0 �0p160 Contact name: Application submittal fee: `' Additional fees: Estimated value of work is required(f over$5,000):$ 13 60'.-0 2 Application accepted: (within the public right-of-way) By: � ( Date: O�L� re Is work related to a LAND-USE DECISION? El Yes reviewed: Yes PKvo t�`'� y n If so, please specify (MLP, SDR,SUB,etc.) case #: By: � , Date: Applicant notified: Is work related to a BUILDING PERMIT? ❑ Yes P No By: Date: If so,please specify(BUILDING PERMIT)case#: ':""""`"\M*stem\LwW UseApp'o"°"' "•".07/09/2015 City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.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 die purchaser of record or a lessee in possession with written authorization from the owner or atr agent of the owner. The owuer(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 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. SIGN IE o h o er of the subject property required. Applicant/Authors Agent's signature Print name Date Owner's signature Print name Date Owner's signature Print name Date Owner's signature Print name Date PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard 13125 SSV Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov 503-718-2421 • Page 2 of 4 ~DEVELOPMENT ENGINEERING FEES Public Facility Improvement (PFI)Permit: DETAILED SUBMITTAL REQUIREMENTS APPLICATION FEE Part 1: Required submittal fee$300.00 FULL SCALE DEVELOPMENT PERMIT FEE (Subdivisions/Partitions and Street Improvements) Part 2: All non-water system improvements Engineer's estimate X 5% (less$300.00 submittal fee) Design Plans Engineer's estimate X 2%Plan Review (6 sets,24x36 or 22x34) ❑ Cover—Site,Vicinity,Abbreviation,Legend WATER SYSTEM FEE ❑ General Notes(City,Water,Sewer,etc.) Part 3: All public water system improvements ❑ Street(Plan,Profile) Engineer's estimate X 12% ❑ Water,Storm and Sanitary(Plan Profile) ❑ Water Quality Facilities PFI Permit Fee Exemptions: ❑ Grading There will be no permit fee charged,or assurance required ❑ Landscaping/Tree Plan for the following types of work: ❑ Composite Utility Plan(Electrical,Phone,Gas, • Sidewalk repair(less than 20 lineal feet) Storm,Sanitary,Water,Signage,Street Lights,etc) • Relocate or replace mailbox ❑ Details • Ditch cleaning that does not involve regrading. ❑ Traffic Sight Distance • Weephole repair ❑ Signing and Striping • Curb repair or replacement (less than 20 lineal feet) ❑ Street Light Plan and Photometric • Lawn sprinkler system installation or repair ❑ Engineers seal/signature • Street tree pruning or planting ❑ Sheet label(project land use name,revision and • Planter strip landscape maintenance plan log block,dates and sheet numbers.) • Test wells Additional Submittals (per Land Use conditions) Note: A cash assurance may be required per El Traffic Report TMC 15.04.140.(customer deposit) ❑ Storm water Drainage Calculations ❑ Geotechnical Report ❑ Preliminary Access Report(Sight Distance) ❑ Proposed Plat ❑ Pathway Design(if applicable) ❑ Water Department Approval SIDEWALK/DRIVEWAY& UTILITY CONNECTIONS,ETC. (work'in the right of way) Sketcb(including information below) ❑ Dimensions ❑ Street Name ❑ Site Address PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • ,vww tigard-or.gov • 503-718-2421 • Page 3 of 4 � 1 SAMPLE SKETCH: St I Edge of P avemerA Ditch n Streetlight I —•-----•—•--- —r--- I I I `o ' a T–'�iop'os cf'Se1werTine I N1 I ►� I i1 Existing Hous- I I Existing i >1 Driveway a 01 1 Eo a i �Jt 3 o rl� ; i CP1s i I j �J � Existing Shop j Povrerpole I I Y I " o I--------7rop rh'e�sine-------�--- I I Fir Hydrant(FH) � � I Scale: 1-=30' � I I I � I � I I � I � 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 City of Tigard - 13125 SW Hall Blvd. • Tigard,Oregon 97223 - wwwtigard-or.gov - 503-718-2421 - Page 4 of 4