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Clean Water Services File Number
CleanWater\` Services 16-003113
Sensitive Area Pre-Screening Site Assessment
�. Jurisdiction: Tigard
2. Property information (example 1 S234AB01400) 3. Owner Information
Tax lot ID(s): 1S125DA03800 Name: Vitaly Kovalev
Company:
Address: 6990 SW Canby St
Site Address: 6613 SW Walnut i errace City,State,zi :Portland OR 97223
City,State,zip:/ igard, SW 69th OK 9/223 Phone/Fax: 503-522-1499
Nearest Cross Street: E-Mail: birchvalleyhomes@gmail.com
4. Development Activity(check all that apply) 5. Applicant information
® Addition to Single Family Residence(rooms,deck,garage) Name: Vitaly Kovalev
D Lot Line Adjustment Minor Land Partition Company:
Residential Condominium El Commercial Condominium Address: 6990 SW canby St
Residential Subdivision ] Commercial Subdivision Portland, UK 9/223
Single Lot Commercial D Multi Lot Commercial City,State,Zip:
Other Phone/Fax: 503-522-7499
E-Mail: birchvalleyhomes@gmail.com
6. Will the project involve any off-site work? Dyes g]No 0 Unknown
Location and description of off-site work
7. Additional comments or information that may be needed to understand your project
Demolition of the house & garage
This application does NOT replace Grading and Erosion Control Permits,Connection Permits,Building Permits,Site Development Permits,DEQ
1200-C Permit or other permits as issued by the Department of Environmental Quality,Department of State Lands and/or Department of the Army
COE, All required permits and approvals must be obtained and completed under applicable local,state,and federal law.
By signing this form,the Owner or Owner's authorized agent or representative,acknowledges and agrees that employees of Clean Water Services have authority
to enter the project site at ail reasonable times for the purpose of inspecting project site conditions and gathering information related to the project site, I certify
that I am familiar with the information contained in this document,and to the best of my knowledge and belief,this information is true,complete,and accurate.
Print/Type Name Vitaly Kovalev Print/Type Title owner
Signature ' ;: R, , . Date 8/16/16
FOR DISTRICT USE ONLY
J Sensitive areas potentially exist on site or within 200'of the site. THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO ISSUANCE OF A
SERVICE PROVIDER LETTER. If Sensitive Areas exist on the site or within 200 feet on adjacent properties,a Natural Resources Assessment Report
may also be required.
❑ Based on review of the submitted materials and best available information Sensitive areas do not appear to exist on site or within 200'of the site.This
Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect water quality sensitive areas if they are subsequently
discovered.This document will serve as your Service Provider letter as required by Resolution and Order 07-20, Section 3.02.1. All required permits and •
approvals must be obtained and completed under applicable local,State,and federal law,
Based on review of the submitted materials and best available information the above referenced project will not significantly impact the existing or potentially
sensitive area(s)found near the site.This Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect additional water
quality sensitive areas if they are subsequently discovered.This document will serve as your Service Provider letter as required by Resolution and Order
07-20,Section 3.02.1. All required permits and approvals must be obtained and completed under applicable local,state and federal law.
❑ This Service Provider Letter is not valid unless CWS approved site plan(s)are attached.
❑ The proposed activity does not meet the definition of development or the lot was platted after 9/9/95 ORS 92,040(2). NO SITE ASSESSMENT OR
SERVICE PROVIDER LETTER IS REQUIRED,
Reviewed by L 4.1„,„4044114.---' Date 8/17/16
2550 SW Hillsboro Highway • Hillsboro,Oregon 97123 • Phone;(503)681-5100 • Fax:(503)681-4439 • www.cleanwaterservices.org