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PFI2016-00161 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12016-00161 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 08/02/2016 Parcel: SEG 898 Jurisdiction: Tigard Site address: 12666 SW KAREN ST 1 Subdivision: BELLWOOD TERRACE CONDO Lot: 1 Project: Driveway approach repair Project Description: Driveway approach repair @12666 SW Karen Owner: FEES Description Date Amount PHONE: Contractor: PHONE: FAX: Applicant: MARK CHRISS 25350 SW GARDEN ACRES RD SHERWOOD, OR 97140 PHONE: 503-519-2790 Total $0.00 0 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 Not Present Signature: Issued By: ---�— -C _ Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12016-00161 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/[ 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/[ 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 R E E I V E D AUG 0 2 2016 City 0f Tigard CITY OF TIGARD PUBLIC WORKS— ENGINEERING PLANNING/ENGINEERING Public Facility Improvement (PFI) Permit DESCRIPTION OF WORK(in the right-of-way) -TYPE 011 RK - Check one: ❑ Utility Connection [-1 TYPE 1 Franchise Utilitv Work XSidewalk/driveway approach Work performed by NWN,PGE ❑ Street improvements and/or utility agency. Detailed description: f4gyb `TYPE 2-Sidewalk/Driveway/Sewer RE yrs // Work performed for the purpose of: -w • Sidewalk installation or repair. • Driveway approach installation Property address/location(s): 1�otyQ SW -Vaa ] and/or repair _rte, T Sanitary sewer lateral installation �T �� and/or main line tap OR ❑ TYPE 3-Full scale Development Applicant: Inc Work performed with Land use approval which includes any of Address: the following: City/state: _ [�_ _ Zip: • Subdivisions or Partitions Phone5o_(Az-dqb � laz 1Q . • Streetwidening Contact name:MaM CII Phone: , ��A- 1 1-�!-�q/Q • Mainfinc installation for Sanitary sewer,Storm sewer,Tigard water Contractor: i3afflQ, ��Q and/or Tigard Water Service Area CCB#: Expiration; p €pj61p Address: _-- -- --------- —�_ _-- City of Tigard City/state: Zip: Planning/Engineering 13125 SW Hall Blvd. Phone: 1;mail: Tigard, OR 97223 Contact name: Phone: Applications for"minor work in right-of-way" only may be emailed to: Engineer: rm"er mitsntigard-or.= Address: City/state: Zip: • R STAFF-USE ONLY Phone: _ Email: Case No.: Contact name: ;lpplication suhmirt-il fee: # /' Additional fees: Estimated value of work is required(if over$5,000):$ Applicarion ac ccptccf: (within the public right-of-way) By ;'1 &I'<0 ,` pplication revie\ved: Is work related to a LAND-USE DECISION? E] Yes &I' 0 By, ,�.a�te�� bate: If so,please specify(MLP, SDR,SUB, etc.) case #: �/ Applicant ottiified: ibII Is work related to a BUILDING PERT? ❑ Yes I�No. - B): _a Date: j a If so,please specify(BUILDING PEIM111)case#: \Q1RFU7\Macters\land Use Apppndons o>tOslio�s F Cityof Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97923 wwwtigard-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 APPLICANT(S) SHALL CERTIFY THAT: • The above request does not viols any deed restrictians that tray be attached to or imposed upon the subject_t groperty. • 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 die 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 die 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. 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 www..tigard-or.gov 503-713-2421 • Page 2 of 4 Ask aw 40 ti lenace i _ Ne 6x8' Concrete Repair 1