PFI2016-00056 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12016-00056
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 03/14/2016
Parcel: SEG3016
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Burlew
Project Description: Abandon original sewer line; install new independent sewer line from the home to the branch under the
sidewalk.
Owner: FEES
Description Date Amount
PFI Permit Fee 03/14/2016 $300.00
PHONE:
Contractor:
ROOT EXCAVATION
10824 SE OAK ST.#322
MILWAUKIE, OR 97222
PHONE: 503-656-6610
FAX:
Applicant:
STEPHANIE SIMON
10824 SE OAK ST.#322
MILWAUKIE, OR 97222
PHONE: 503-656-6610
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
Signature: Not Present
Issued By: ---�— <
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12016-00056
Tyne: Condition Name: Status: SevUftyL
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 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.
Kenny Fisher at 503-816-6146
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
RECEIVED
City of Tigard MAR 10 2016
_ ~ PUBLIC WORKS—ENGINEERING CITY OF TIGARD
Public Facility Improvement (PFI) PernutNNINENGINEERING
DESCRIPTION OF WORK(in the right-of-way) TYPE OF WORK
Check one: ❑ Utility Connection
sidewalk/driveway approach ❑ TYPE 1-Franchise Utility Work
Work performed by NWN,PGE
El Street improvements and/or utility agency.
Detailed description: Abandon original sewer line; Install new ❑ TYPE 2-Sidewalk/Driveway/Sewer
independent Sewer line from the home to the branch under the Work performed for the purpose of:
sidewalk. • Sidewalk installation or repair.
• Driveway approach installation
Property address/location(s): 12514 SW 115th,Tigard, OR 97223 and/or repair
• Sanitary sewer lateral installation
and/or main line tap
XTYPE 3-Full scale Development
Applicant: Work performed with Land use
Address: approval which includes any of
the following:
City/state: Zip: • Subdivisions or Partitions
Phone: Email: • Street widening
Contact name: Phone: • Mainline installation for Sanitary
sewer,Storm sewer,Tigard water
Contractor: Root Excavation and/or Tigard Water Service Area
CCB#: 134498 Expiration: 4/27/2017
SUBMIT COMPLETED APPLICATION TO:
Address: 10824 SE Oak Street, # 322 City of Tigard
City/state: Milwaukee, Oregon Zip: 97222 Planning/Engineering
Phone:503-656-6610 Email:xttpkaniepraglanlainc,c*n, 13125 5W Hall Blvd.
Contact name: Stephanie Simon Phone: 503-656-6610 Tigard,OR 97223
Applications for"minor work in right-of-way"
only may be emailed to:
Engineer: rowAigaaL_QL=v
Address:
City/state:
"Lip:
Phone: Email: Case No.:-?F_T ZZ i -L,9O o 5-(o
Contact name: Application submittal fee: ,2_Z)C)-- —
Additional fees:
Estimated value of work is required(if over$5,000):$ Application accepted:
(within the public right-of-way) By: �i►ti— Date
Is work related to a LAND-USE DECISION. ❑ yes Applicati
� ❑ No
If so,please specify(MLP, SDR,SUB,etc.) case #: By: Date: 3 l 1 Zo 1
Applicant notified:
Is work related to a BUILDING PERMIT? Yes [INo BT Date: (�
If so,please specify(BUILDING PERMIT)case#:PLM2016-00118 1C1RPtN\fAasters\La dUse Applic b— Rev 07/0012015
T
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 www.tigard-or.gov 503-718-2421 • Page 1 of 4
I
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 APPLICANT(S) SHALL CERTIFY THAT:
• The above request does not violate any deed restrictions that may be attached to or imposed umn the subject prop.
• 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 eilgh owner of the subject property required.
j24 1-0
4ie—Jb#
Stephanie Simon March S, 2016
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
Cityof Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2421 • Page 2 of 4
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