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PFI2016-00235 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12016-00235 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 11/01/2016 Parcel: 2S 112CA04400 Jurisdiction: Tigard Site address: 15185 SW 79TH AVE Subdivision: DURHAM ACRES Lot: 36 Project: J.T. Roth Construction Project Description: Connect existing home to sewer Owner: FEES Description Date Amount PFI Permit Fee 11/01/2016 $300.00 PHONE: Contractor: PHONE: FAX: Applicant: DAVID JENSEN 12600 SW 72ND TIGARD, OR 97223 PHONE: 503-639-2639 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 L-3 / f� + h Signature: `� GSI f e l l a.� L ,to Issued By: 1 J f l U � " Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12016-00235 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/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/[ 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. Engineering inspector must be onsite at time of connection to mainline, call for inspection. 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 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12016-00235 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 11/01/2016 Parcel: 2S112CA04400 Jurisdiction: Tigard Site address: 15185 SW 79TH AVE Subdivision: DURHAM ACRES Lot: 36 Project: J.T. Roth Construction Project Description: Connect existing home to sewer Owner: FEES Description Date Amount PFI Permit Fee 11/01/2016 $300.00 PHONE: Contractor: PHONE: FAX: Applicant: DAVID JENSEN 12600 SW 72ND TIGARD, OR 97223 PHONE 503-639-2639 Total $30000 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. ttlicant SignPermittee/Applicant �--1 Signature:ure: Issued By: 1✓ 1 U �"`"' Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12016-00235 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/[ 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. Engineering inspector must be onsite at time of connection to mainline, call for inspection. 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 RECEIVED City of Tigard OCT 27 2016 PUBLIC WORKS — ENGINEERING CITY OF TIGAFU Public Facility Improvement (P]F )NFVftft-!`���� TYPE OF WORK DESCRIZlut6ihties N OF WORK(in the right-of-way) El TYPE 1-Franchise Utility Work Check one: ❑Sidewalk/driveway pproach ElStreet improvements performed by NWN, PGE Detailed description: Car/i�EP7r0� ls>' �UF and/or utility agency. /T� ✓� �� ����fC S��r / TYPE 2-Sidewalk/Driveway/Sewer �'✓ Work performed for the purpose of: l • Sidewalk installation or repair. /`/�r `� • Driveway approach installation Property address/location(s): i 7 ✓ / and/or repair • Sanitary sewer lateral installation and/or main line tap El TYPE 3-Full scale Development Applicant: T �r71/r 't '���'✓ Work performed with Land use Address: �ZvrUV s �L— approval which includes any of City/state: 71_e 'lam' A, Zip: '�i/;7 ZIJ the following. Phone:�- 2_2`1�y Email: E1 a e%1*1 • Subdivisions or Partitions Contact name Phone:r z q1D6-a a Z - Street widening • Mainline installation for Sanitary Contractor: sewer, Storm sewer, Tigard water and/or Tigard Water Service Area CCB#: /fes / Expiration: Address: //,)oA 11f1✓if,K /M— SUBMIT COMPLETED APPLICATION TO: City/state: i�h- Zip: 1 City of Tigard Phone: O,T /J�Email: gYfe' - (' jyr Planning/Engineering 13125 SW Hall Blvd. Contact name: n�� L� Phone:.SJ3 1s?6 -7745, Tigard,OR 97223 Applications for"minor work in right-of-way" only may be emailed to: Engineer: rowpermits(a tigard-or.gov Address: City/state: Zip: f Phone: Email: Case AF/Q'-)Jle o.:OOQ3S7 Contact name: Application submittal fee: OCA oU Additional fees: Estimated value of work is required(if over$5,000):$ Application accepted: Z (within the public right-of-way) By: _ Date: Is work related to a LAND-USE DECISION? ❑ Yes ❑ No Application reviewed: f T If so,please specify (MLP, SDR,SUB,etc.) case #: By.'R,,SS _ Date: OL l Applicant notified: Is work related to a BUILDING PERMIT? ❑ Yes ❑ No By: Date: If so,please specify(BUILDING PERMIT)case#: I:\CURPLN\Masten\Land Use Appliotions Rev.09/26/2016 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,if required by the city pursuant to TMC 15.041.140. * With the exception of a utility operating pursuant to a valid franchise with the City of Tigard,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. Franchised Utilities are not required to obtain the owner's signature on the application BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT: • The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject ro e • 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 any 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. Applicant/Autho ' ed Agent's signature Print name Date SIGNATURES of each owner of the subject property, if required. 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 503-718-2421 • Page 2 of 4 v Y DEVELOPMENT ENGINEERING FEES FOR STAFF t SE 0 N IN Public Facility Improvement(PFI)Permit: DETAI 1 St 113MITTAL APPLICATION FEE QUI • EMENTS Part 1: Required submittal fee$300.00 FRANCHISE UTILITY AND SIDEWALK/ PERMIT FEE DRIVEWAY AND UTILITY Part 2: All non-water system improvements CONNECTIONS,ETC. Engineer's estimate X 5%(less$300.00 submittal fee) (work in the right of way) Engineer's estimate X 2%Plan Review Sketch (including information below) WATER SYSTEM FEE ❑ Dimensions Part 3: All public water system improvements ❑ Street Name Engineer's estimate X 12% ❑ Site Address PFI Permit Fee Exemptions: FULL SCALE DEVELOPMENT There will be no permit fee charged,or assurance required (Subdivisions/Partitions and Street Improvements) for the following types of work: • Sidewalk repair(less than 20 lineal feet) • Relocate or replace mailbox Design Plans • Ditch cleaning that does not involve regrading. (6 sets,24x36 or 22x34) • Weep hole repair ❑ Cover—Site,Vicinity,Abbreviation,Legend • Curb repair or replacement(less than 20 lineal feet) ❑ General Notes(City,Water,Sewer,etc.) • Lawn sprinkler system installation or repair ❑ Street(Plan,Profile) • Street tree pruning or planting ❑ Water,Storm and Sanitary(Plan Profile) • Planter strip landscape maintenance ❑ Water Quality Facilities • Test wells ❑ Grading ❑ Landscaping/Tree Plan ❑ Composite Utility Plan(Electrical,Phone,Gas, Note. A cash assurance may be required per Storm,Sanitary,Water,Signage,Street Lights,etc) TMC 15.04.140.(customer deposit) ❑ Details ❑ Traffic Sight Distance ❑ Signing and Striping ❑ Street Light Plan and Photometric ❑ Engineers seal/signature ❑ Sheet label(project land use name,revision and plan log block,dates and sheet numbers.) Additional Submittals (per Land Use conditions) ❑ Traffic Report ❑ Storm water Drainage Calculations ❑ Geotechnical Report ❑ Preliminary Access Report(Sight Distance) ❑ Proposed Plat ❑ Pathway Design(if applicable) ❑ Water Department Approval PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 3 of 4 v SAMPLE SKETCH: ~ Edge of Pavement Ditch Streetlight I -------------Drain —C--- f I ' ice.i 1 i —�ro'pos d'Se1�werTitie" i "i Existing House 1 �� I Existing �� Q �r - Driveway IL CI w �/y• I i I i CFAs i o Existing Shop Powerpole I I old �. I 951 1 I -- -------rropeVl_ine------- - I I - •� 1 II Fire Hydrant(FH) I � I Scale: 'I"=30' � � I I I I ' I I MINIMUM SKETCH REQUIREMENTS (Put"N/A"if Not Applicable): North arrow Property lines &dimension Slope of property Street &street name(s) Existing building,structures Utility &street light poles Proposed work Existing curb or edge Trees Existing S/W or of pavement Existing utility locations D/W apron (sewer,water,storm) L� PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard - 13125 SW Hall Blvd. - Tigard,Oregon 97223 - www.tigard-or.gov - 503-718-2421 - Page 4 of 4 I I 7,872 SF ' — — tae' — 64 I I I I 10' I I 1 I I I I I 'Io I 5 4 3 2 6,003 SFI 6,004 SF 6,535 SF 6.243 SF I I ' I I 3T I I II I — 64' 7 z I w LU Q Q IW I 1 00 I I 6 �I 9 �I 1 O I I I I 6.727 SF 6,789 SF I 7,182 SF -- 90 - - -- 90 , I I I I 1 I I I I I I I ( I I 7 $ I^ 7,158 SF I I 7,452 SF °�' 16,430 SF I I I EXISTING HOUSE of _ II I I ar _ _ � �1/ATER QUALITY ~��� /I w 20' 21' _ _ _ _ _lir _ _ _ _ __ _77• _ FUTURE STREET ALIGNMENT — — —— — — — — — — — — — — 20-FOOT STORM AND SANITARY EASEMENT = \ H 1 � I - - - - - - - - - r- u, I 1 (� SAI 5-IL -6 1! 81ST AVENUE G I I I I I I 1 a I� I I I I I I I I I — 75' I I 00 I I I 1 p A $) Q m I I r I I I Nc a I I Z8 �N I m I 75 '0— 2S 5Y � I m � I I I I m I m I I m I I _ 110, J 72' j 98' N m I I a 1 a N al I D T ` 50 m / 80TH AVENUE o CD I dol I 0 I I ° I � Dic Q1,0100S�r� I Z cn I rxfS� I < I K I E 7AII-11� dr 6,,Pfiv z 10 I Izm 79TH AVENUE