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PFI2017-00041 r CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT ■ COMMUNITY DEVELOPMENT Permit#: PF12017-00041 13125 SW Date Issued: 03/15/2017 Hall Blvd ,Tigard OR 97223 503.71 421 Parcel: 2S103BA00111 Jurisdiction: Tigard Site address: 12005 SW ANN ST Subdivision: LERON HEIGHTS Lot: 11 & PT 10 Project: Pugh Driveway Approach Project Description: Remove and replace driveway approach Owner: FEES Description Date Amount PFI Permit Fee 03/15/2017 $300.00 PHONE: Contractor: PHONE: FAX. Applicant: LEX FUSITUA PHONE: 503-810-3752 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. r Permittee/Applicant Signature: �! Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12017-00041 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/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/[ 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/[ 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 RECEIVED PUBLIC WORKS — ENGINEERING MAR 15 2017 Public Facility Improvement ftfta�t TYPE OF WORK DESCRIPTION OF WORK(in the right-of-way) Q� El TYPE 1—Franchise Utility Work Check one: ❑ Utilities Dd'Si alk/drivewa•approach ❑Street improvements performed by NWN, PGE Detailed d scription: r f1v LPA and/or utility agency. +✓ TYPE 2—Sidewalk/Driveway/Sewer Work performed for the purpose of: • Sidewalk installation or repair. ..l • Driveway approach installation Property address/location(s): `�`� >�N� ST ' and/or repair • Sanitary sewer lateral installation and/or main line tap Applicant: ❑ TYPE 3—Full scale Development PP 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 • Mainline installation for Sanitary Contractor: fi?ym sewer, Storm sewer,Tigard water '��, CCB#: ��1d��I Expiration: and/or Tigard Water Service Area Address: TV9!X :2=W-712 SUBMIT COMPLETM"PLICATION TO: City/state: Tle, , g Zip: !Fr J V . I City of Tigard Phone: C5� -F>16-31 mail: A4eA WVZ A �l�W Iil�C1�(1� iC�2l Planning/Engineering I . 13125 SW Hall Blvd. Contact name: Phone: Tigard,OR 97223 Applications for"minor work in tight-of-way" Engineer: only may be emailed to: rowpermitsna tigard-or.gov Address: FOR STAFF USE ONLY City/state: Zip: Phone: Email: Case No.: PFJe p /7:� Contact name: Application submittal fee: $ � Additional fees: $ Estimated value of work is required(if over$5,000):$ Application accepted: (within the public right-of-way) By: ALS� Date: Is work related to a LAND-USE DECISION? ❑ Yes No Application reviewed: / �Date: If so,please specify (MLP,SDR,SUB,etc.) case #: By:_�� Applicant notified: Is work related to a BUILDING PERMIT? ❑ Yes No By: Dare: 3R IAENG\PermitAppikations\pfi application Rev.12/16/2016 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,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 Cit}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 owners 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 re reme s for approving or denying the application. cnt/A o ent'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 C � 12-0 Y 7 l� 4J. Vaca�,L Xw'I vi F(CA�� r 7 r v -7,T y� q ��Y 3 IZZ IGx�snnf ` ( l &,If rfiry Carr t(ac►n .,�r V) I C 3 t � 2-a V C, Xw of FtYrKy I{ c4&.qs rfu&-" ' TT- 6r.13 acu l,e I ?,� vruu -- ple ra it t i Ij