PFI2017-00037 1-r- 21
CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12017-00037
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 03/21/2017
Parcel: SEG1824
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Pacific Crest Sewer Repair PFI
Project Description: Sanitary Sewer repair
Owner: FEES
Description Date Amount
PFI Permit Fee 03/21/2017 $700.00
PHONE:
Contractor:
BLACK ROCK UNDERGROUND LLC
PHONE:
FAX:
Applicant:
CORY MOORE
267 NE 34TH PL
HILLSBORO, OR 97124
PHONE: 503-747-9312
Total $700.00
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.
Perm ittee/Applicant �.
Signature: ?
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12017-00037
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/1 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/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/[ 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. call Jonny Gish 971-713-0281 or Jonny@tigard-or.gov
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
I NtL;EIVED
City of Tigard MAR 14 2017
PUBLIC \VORKS — ENGINEERING CITY OFTIGARD
i PLANNING/ENGINEERING
Public.Facility Improvement (PFI) Permit
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way) ❑ TYPE 1-Franchise Utility Work
Check one:—XUtditles A Sidewalk/driveway approach ❑Street improvements performed by NWN, PGE
Detailed description: 'T�NyZAe.1,v. Sv.,,-) x-etcAa p and/or utility agency.
TYPE 2—Sidewalk/Driveway/Sewer
Work performed for the purpose of:
�1 1 • Sidewalk installation or repair.
ProperA
address/location(s): 5W • Driveway approach installation
Pro
P G�h W h� ,�btQ_. and/or repair
14 � • Sanitary sewer lateral installation
and/or main line tap
Applicant: ��a wx, ❑ TYPE 3—Full scale Development
Work performed with Land use
Address: approval which includes any of
City/state: Zip: the following:
Phone: Email: Subdivisions or Partitions
• �'
Contact name: Phone: Street widening
1 0 Mainline installation.f6r Sanitary
Contractor: { (,`L o `'� f t •t V o� L•L L sewer, Storm sewer;'Tigard water
and/or Tigard Water Service Area
CCB#: 1016 Wok � Expiration:
Address: a C_p7j jklC- b7 %Ak`N D`1 SUBMIT COMPLETED APPLICATION TO:
City/state: O Ci Zip: City of Tigard
Plannin /En ineerin
Phone: a 3.1'�1.9311- Email:'++n�o @��r.c1E.t'oc lr.vrrt�,er aeo •u+v� 13125 SW Hall Blvd.
Contact name: Loa-`2 MooR.L- Phone: Tigard,OR 97223
o 10 D Applications for"minor work in right-of-way"
only may be emailed to:
Engineer: rowperrnitsna tigard-or.gov
Address:
FOR STAFF USI,' ONLY
City/state: Zip:
Phone: Email: Case No.: eFS 20 00031
Contact name: Application submittal fee: '02f-)d 'C
Additional fees:$
Estimated value of work is required(if over$5,000):$10/000, ' Application accepted:
(within the public right-of-way) By: (Ina Date: 3/14 /1-7
Is work related to a LAND-USE DECISION? ❑ Yes �J No Application reviewed:�•112, Date:
If so, please specify (MLP,SDR,SUB, etc.) case #: By:V
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes ❑ No By: Date:
If so,please specify(BUILDING PERMIT)case#: L\ENG\PermitApplications\pfi_appiication Rev.12/16/2016
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City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wawv.tigard-or.gov • 503-718-2421 Page 1 of 4
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STORM OR SANITARY STAINLESS STEEL
MAIN BAND
NOTES:
1. INDEXED PVC GASKETED SADDLE SHALL CONFORM TO ASTM 3034 SDR35.
2. PVC COMPOUNDS SHALL CONFORM TO ASTM D1784 WITH CELL CLASS OF 12454—B/C
OR 12364—C.
3. ALL ELASTOMERIC SEALS (RUBBER GASKETS) SHALL CONFORM TO ASTM F477.
4. INDEXED PVC GASKETED SADDLE SHALL BE INSTALLED WITH RUBBER GASKETS
APPROVED FOR THE SEWER MAIN WALL CONFIGURATION (PROFILE OR SMOOTH WALL).
5. STAINLESS STEEL BANDS SHALL BE 300 SERIES, %6" BAND WIDTH, CADMIUM PLATED,
CARBON STEEL, AND ATTACHED WITH HEX HEAD, SLOTTED SCREWS.
6. INSERTION HOLE SHALL BE CORE DRILLED.
7. INDEXED SADDLE SHALL BE INSERTED A MINIMUM OF Y4" FROM OUTSIDE WALL OF
HOST PIPE AND SHALL NOT PROTRUDE BEYOND THE INSIDE WALL OF THE HOST PIPE.
INDEXED PVC GASKETED
C1eanWate\ Services
DRAWING N0. 540 REVISED 12-06
SADDLE •ur commitment is clear.
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NOTE:
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2. JOINTS TO BE TACK AND SANDED.
3. SAWCUT SHALL BE TACK COATED WITH BITUMINUS ASPHALT EMULSION.
CATY OF TIGARD APPROVED BY: NO SCALE
OREGON MICHAEL A. STONE, P.E.
ENGINEERING DIVISION CITY ENGINEER TRENCH DWG. NO.
PUBLIC WORKS DEPARTMENT
S.W.HALL BLVD.
TIG O
TIGARD,OREGON 97273 JANUARY 2013 BACKFILL
L VOICE:(503)6394171
FAX: (503)684-7297 APPROVAL DATE