PFI2016-00104 n CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12016-00104
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 05/18/2016
Parcel: SEG1824
Jurisdiction:
Site address:
Subdivision: Lot:
Project: City of Tigard
Project Description: UTILITY POTHOLING FOR CITY CIP 94033
Owner: FEES
Description Date Amount
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
CHRIS DUNHAM
43530 SE NORTH BEND WAY
NORTH BEND,WA 98045
PHONE: 425-888-2590
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: ^--ti—
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12016-00104
Type: Condition Name: Status: Severity:
PFI—Sidewalk/1 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/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/1 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/1 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/1 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
RECEIVE®
City of Tigard MAY 18 2016
_ PUBLIC WORKS —ENGINEERING p CITY
II I Y OF GIARD
RING
Public Facility Improvement (PFI Permit
DESCRIPTION OF WORK(in the right-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: 1111 r i.4y pyi 6 l i lq To✓ 6'4Y 0 TYPE 2—Sidewalk/Driveway/Sewer
6W Q 9 4b 33 Work performed for the purpose of:
• Sidewalk installation or repair.
• Driveway approach installation
Property address/location(s): SW kw"( and/or repair
n • Sanitary sewer lateral installation
l0(0 A JE• and/or main line tap
❑ TYPE 3—Full scale Development
Applicant: /SPS, ZNc., l' p Work performed with Land use
Address: 43530 SE Alo�f414 BeoA Woy approval which includes any of
the following:
City/state: ti6MA geoid WA _ Zip: q$o,c 5 • Subdivisions or Partitions
Phone:4zC-Q8g-ZS90 Email: Jw✓;sc(P_apsioz-AtS.4�oM • Streetwidening
Contact name: C 6f i S Mo6daw, Phone: 266-5 71 -1867 e Mainline installation for Sanitary
sewer,Storm sewer,Tigard water
Contractor: SawIC. AS QP f j',6CtA1 and/or Tigard Water Service Area
CCB#: ISO 130 Expiration: SUBMIT COMPLETED APPLICATION TO:
Address: City of Tigard
City/state: Zip: Planning/Engineering
13125 SW Hall Blvd.
Phone: Email: Tigard,OR 97223
Contact name: Phone: Applications for"minor work in right-of-way"
11 only may be emailed to:
Engineer: GAti ok rampermitsgtigard-or.gov
Address: 13l ZS So HAI MVA.
City/state: TLgafA 0I Zip: CO2,- 3
Phone:S03-11i-1-41-1- Email: av►drewh Case No.: fl 12-0/U—00104
Contact name: Ay%Aee,J fyk_40ry .Application submittal fee: O7—
Additional fees:
Estimated value of work is required(if over$5,000):$ too 066 ApplicaWna epted:
(within the public right-of-way) Date: G
Appli do eviewed:
Is work related to a LAND-USE DECISION? ❑ Yes No g f
Date:
If so,please specify (MLP,SDR,SUB,etc.) case #:
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes M No By: Date:
I:\CURPLN\Masters\Land Use Applications Mv.07/09/2015
If so,please specify(BUILDING PERMIT)case#:
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 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 APPLICANTS) SHALL CERTIFY THAT:
• The above request does not violate any deed restrictions that may be attached to or imposed upon the subject properrn.
• 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
requircmcnts 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 signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
Cityof Tigard • 13125 SW Fall Blvd. • Tigard,Oregon 97223 • xv,,vwtigard-or.gov 503-718-2421 • Page 2 of 4