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PFI2017-00069 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT = COMMUNITY DEVELOPMENT Permit#: PF12017-00069 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 04/18/2017 Parcel: SEG2270 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: Rose City Concrete Project Description: Removing and replacing parts of sidewalk along SW Summerfield Dr Owner: FEES Description Date Amount PFI Permit Fee 04/18/2017 $30000 PHONE: Contractor: ROSE CITY CONCRETE REPAIR&CONSTRUCTION 3300 NW 185TH STE 183 PORTLAND, OR 97229 PHONE: 503-232-9702 FAX 503-352-4768 Applicant: MADISON CONNOLLY 3300 NW 185TH STE 183 PORTLAND, OR 97229 PHONE: 503-232-9702 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 Signature: See application 01 Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12017-00069 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/[ 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 ken fisher at 503-816-6146 or Kenny@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 RECEIVED 11 City of Tigard APR 13 2017 PUBLIC WORKS —ENGINEERING CITY OF TIGARD Public Facility Improvement'(Pr1YP rM TYPE OF WORK DESCIU Y- 'ION OF WORK(in the right-of-way) ❑ TYPE 1—Franchise Utility•Work Check one: 0 Utilities kidewalk/driveway approach ❑Street improvements performed by NWN, PGI'-, Detailed Iesctiption: �. Av. C and/or utility agent-. TYPE 2—Sidewalk/Dm ewav/Suver Fork performed for the purpose of: -- • Sidewalk installation or repair. \ • Drivmway approach installation Pmpertv address/location(s): 1 M&_A a()iAJ�Occa-1�. and/or repair (2 • Sanitary sewer lateral installation and/or main line tap Work orW Applicant: _� is r s t r1 Cpn r+.i�� ElTYPE —Full scale Development VFperformed with land use Address: _ ':_�oo Nwn kg&—iils3approval which includes amt of City/state: _�UrNArd L Zip: g112A the following: Phone:!' t . Email: (O� c }�CbnCtQ�( �['r1y.�Ylc • Subdivisions or Partitions Contact n arty!: Phone: • Street widening 1 ((//'��, e • Mainline installation for Sanitary COntraetcr: Aose— C,\4 Gt1ue�c sewer, Storm sewer, Tigard water ,� and/or Tigard\Fater Sen ice Area CCB#: -_59)\!A A-5 Expiration: Li•A•ZQI� Address: _ S;CSO \V W n , U5'» f t Jt �1 ,� SUBMIT COMPLETED APPLICATION TO: City/state, _S)O'� 11,Y\6 (,DQ-. Zip: G111!2. City of Tigard Phone: C1 q Email: `y Planning/Engineering 13125 SW Hall Blvd. Contact n uni t: hone:=_'N.i,7) C�7!7LL Tigard,OR 97223 Applications for"minor work in right-of=way" Engineer:-- only mac be emailed to: ro rrnitsrakigaard-or.°ov Address: City/state Zip: Phone:_ Email: Casc No.: Contact n:mc, Application submittal fee: S 300-O O Additional fees:S Estimated val to of work is required(if over$5,000):$ Application accepted: / (within tht In blic right-of-way) By: 4S 41310— Is work re ai:e l to a LAND-USE DECISION? ❑ Yes Application reviewed:No / By�7��1-- nate: N I(4/0 If so,please specify(] ILP,SDR,SUB,etc.) case#: Applicant notified: Is work relat:ej to a BUILDING PERMIT? ❑ Yes 0 No BS'- �_J Date: �11� If so,please specify(BUILDING PERIVII'1)case#: 0Jtnc\r•m ft4p aVa W#Wka0o„ eo,.22/16/2016 Cityof Tigard 13125 SW Hall Blvd. Tigard,Oregon 97223 www.tigircl-or.gov 503-718-2421 Page 1 of 4 APPLICANTS NOT13: 3erson specified as"Applicant"shall be designated"Permittce"and shall provide financial assurance for work,if required Ly the city pursuant to Tl IC 15.041.140. * With tt a exception of a utility operating pursuant to a valid franchise with the Cin•of Tigard,when the owner and the applicant are di fferent peopie,th a applicant must be the purchaser of record or a lessee in possession with written authorization from the owner or an agent of the owner. Tie owner(s)must sign this application in the space prodded or submit a written authorization with this application. Franchised Utilities a e not required to obtain the owner's signature on the application BY SIGNJING BELOW,THE APPLICANTS) SHALL CERTIFY THAT: • The ab c e• equest does not Cholate wy recorded deed restrictions that maLbe attached to or imposed upon the ubicct Franem. • If the alrla.:ation is granted,the applicant will exercise the rights granted in accordance with the terms and subject to all the conditicn;,.nd limitations of the approval. • All of d e a)ove statements and the statements in any plot plan,attachments,and exhibits transmitted herewith,are true,and the appl car is so acknovALdge that any permit issued,based on this application,may be revoked if it is found that any such statement i ure false. • The applica it has read the entire contents of the application,including the policies and criteria,and understands the requirentem s for approving or denying the application. Applicant/A.ithorized Age s signature Print name 04Date SIGNATCFES of each owner of the subject property,if required. OCvner's sign iture Print name Date (Nvner's sign iture Print name Date Owner's signature Print name Date PUBLIC FACILITY IMPROVEMENT PERMIT Cityof'rig and • 13125 S\X'Hall Blvd. • Tigard,Orcgon 97223 • w ww.tigard-ongov 503-718-2421 • Page 2 of 4 DEVEI.0 PMENT ENGINEERING FEES Public F.cit ty Improvement(PFI)Permit: APPL[CI KION FEE Part 1: ltc quired submittal fee$300.00 FRANCHISE UTILITY AND SIDEWALK/ PERMIT FEE DRIVEWAY AND UTILITY Part 2: Ai I 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) WATT R.;,YSTEM FEE ❑ Dimensions Part 3: ,U.public water system improvements ❑ �trect Name Engine:r's estimate X 1207v ❑ Site Address PFI Pt rtn it Fee Exemptions: FULL SCALE DEVELOPMENT There wiI :)e no permit fee charged,or assurance required (Subdivisions/Partitions and Street Improvements) for the foll.)wing types of work: • Sides calk repair(less than 20 lineal feet) • Reloca_e or replace mailbox Design Plans • Ditcl charting that does not involve regrading. (6 sets,24x36 or 22x34) • Weel ho le repair ❑ Cover—Site,Vicinity,Abbreviation,Legend • Curb rep air or replacement(less than 20 lineal feet) ❑ General Notes(City,Water,Sewer,etc.) • I.awr. sprinkler system installation or repair ❑ Street(Plan,Profile) • Stree trt a pruning or planting ❑ Nater,Storm and Sanitary(Plan Profile) • Planta s rip landscape maintenance ❑ Waw Qty Facilities • Test NMI; ❑ Grading ❑ Landscaping/Tree Plan ❑ Composite Utility Plan".ectrical,Phone,Cras, Note: A cash assurance maybe required per Storm,Sanitary,Water,Signage,Street lights,etc) TMC:1!.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 i lse 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 • wwwtil ard-or.gov • 503-718-2421 • Page 3 of 4 V' s � s / tj\ to J+ s