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PFI2016-00006 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT a COMMUNITY DEVELOPMENT Permit#: PF12016-00006 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 01/22/2016 Parcel: SEG350 Jurisdiction: Tigard Site address: 10775 SW SUMMER LAKE DR Subdivision: AMART SUMMER LAKE Lot: 121 Project: Summer Lake Drive PFI Project Description: Repairing damaged HOA meter,fixing a wall and monument light that was hit by a car, meter base on wall wire exposed. Car drove and pinned meter to the wall) Owner: FEES Description Date Amount PHONE: Contractor: PHONE: FAX: Applicant: TSAHAI ANDERSON 10800 SW AVERY ST TUALATIN, OR 97062 PHONE: 503-612-6106 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 Signature: Not Present Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12016-00006 Type: Condition Name: Status: Severity: PFI_Utilities 01 -WORK SITE REQUIREMENTS Not Met 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 Not Met 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 Not Met 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 Not Met 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 Not Met 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 07-TRAFFIC CONTROL ROAD CLOSURE Not Met 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 06-TRAFFIC CONTROL PLAN Not Met 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 08-TRAFFIC CONTROL PROPERTY ACCESS Not Met 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 10-TRAFFIC CONTROL LIMITED WORK HOURS Not Met 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 09-TRAFFIC CONTROL WORK HOURS Not Met 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 11 -TRAFFIC CONTROL MODIFICATION Not Met 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 13-UTILITY LOCATION CONFLICT Not Met 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 12-UTILITY NOTIFICATION Not Met 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 14-TEMPORARY PATCH Not Met 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 Not Met 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 Not Met 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 Not Met 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 Not Met 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 20-EMERGENCY CONTACTS Not Met 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 19-MONUMENT PROTECTION Not Met Notice Existing monuments, property corners, and survey markers shall be protected. Replacement shall be at the permit holder's expense. PFI_Utilities 21 -OTHER Not Met Notice RECEIVED City of Tigard JAN 2 0'2016 r PUBLIC WORKS — ENGINEERING PGE WORK ORDER# M1934017 CITYOF TIGARD Public Facility Improvement (PFI) PeJ'r"ii 'ENGINEERING DESCRIPTION OF WORK (in the right-of-way) REQUIRED SUBMITTAL Check one: R Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS Detailed description: Repairing damaged HOA Meter 8 Minor work in right-of-way (sidewalk repair,curb cut,street (Fixing a car hit wall and monument light on it. meter base on wall opening,etc.)requires: wire exposed. Car drove through and pinned meter to wall) -Application form,completed and signed •Submit one(1)copy of scaled sketch Property address/location(s): 10775 SW Summer Lake Drive, Tigard of the proposed work to be done S rcG-i :950 •Submit one(1)copy of traffic control plan —OR— Tsahai Anderson ❑ Substantial project work requires Applicant's name: above items and professional Address: 10800 SW Avery Street engineered plans for: •Street widening Ci /state: Tualatin OR Zip: 97062 •Subdivision infrastructure Phone: 503-612-6106 Email: Tsahai.Anderson@pgn.com •Main utility line extension: Storm Drain,Sanitary—Tigard PGE Crew Water—Tigard Water Service Contractors name: Area(includes Durham,Kung City CCB#: 103663 Expiration: and a portion of unincorporated Washington County) Address: City/state: Zip: DELIVER APPLICATION TO: City of Tigard Phone: Email: Planning/Engineering 13125 SW Hall Blvd. Engineer's name: N/A Tigard,OR 97223 Applications for"minor work in right-of-way" Address: only may be emailed to: City/state: Zip: ropermitsktigard�or.Qov Phone: Email: FOR STAFF USE' ONIL) Case No.: Estimated value of work (within the public right-of-way): $ Application submittal fee: Is work related to a LAND-USE DECISION? ❑ Yes N No Application accepted- If If so,please specify (MLP, SDR,SUB, etc.) case#: By: `� M6 Date: �! b A�onIs work related to a BUILDING PERMIT? ElAppYes I@ Nowed: By: Date: r If so,please specify(BUILDING PERMIT)case#: V ow t Applicant notified: �• �• (yw,�t .t �.-1' Gw By: I—S Date: 1 1:\LURVLN\Masters\Land Use Applications Re,07/16/2014 Cityof 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 the purchaser of record or a lessee in possession with written authorization from the owner or an agent of the owner. The owner(,,)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 anydeed restrictions that maw,be attached to or imposed 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 an)'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. MgUlly slge by TSAHAI ANDERSON ^^ ^^ Anderson TSAHAI ANDERSON`[214._TSAHAIAANDERSON@PGNCOM,1 ANDERSON,-PGE, �US TSahai / nderson 1/13/16 Date'2018.01.14 13'42'46-08'00' Applicant/Authorized 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 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov 503-718-2421 • Page 2 of 4 R �X � T y 1" '� 12710 12690 � MA 12770 12790 12750 sw scNOt 10555 ��� ' 12870 12850 12820 p 0 p 0 12900 -6 �. 1-� 12744 a 106231062410636 10600 10635 I 1: 10620 10647 � 1 8 i 1281512805 `�, 12855 1283512825 10640 -_ 12730 12700 12845 . �� 10659 _ r 1 GHXCO C-1 M 10680 10673 SW ❑ t� 10700 12820128001 10687 0 12658 12 10720__ 10705 1284 10740 - u am j2M 12860 2850 �' S - 10717 g 10760 Al ' r 1082511, 0 1 r Y 10729 36 off- ` 10780 '� 47 1084510835 r 10741 1073010855 10815 .k�' �� /� 10732 - 10805 � -- �� 10740 11329 L13 10865 J�� 2750 12663 y 127401273212724 Siy 12647 + 11307 12716 S,o 12621 10875 � 10800 ' --�__ � R� 10885 12708 Ry 11285 1089 10820 "h- ` 12694 �4Rcl � � � � . 1267 , 10840 12723 2 W 6 Y 12650' 10860- 12767 ahAl :E 10 mu %li 12701 12638.-%& Z 10880 -- _ 12687 12616 12935 --- 10925 .10900 12778 5512945 _ 12925. 10935 �� -__ 10920 , lr �`' S 1� 1,2fi21 '� 11241 g 1-291 -- .� ! 10940 12665 12756 12734 o 12712 ��Sow'`� *r _ . 260 I 11227 � 1 MW.:CM�. 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