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PFI2016-00151 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12016-00151 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 04/17/2017 Parcel: 2S109BA09200 Jurisdiction: Tigard Site address: 13691 SW LEAH TER Subdivision: DAFFODIL HILL Lot: 18 Project: Fahat Sidewalk Repair Project Description: Repair sidewalk next to 13691 SW Leah Terrace Owner: FEES Description Date Amount PFI Permit Fee 04/10/2017 $300.00 PHONE: Contractor: PHONE: FAX: Applicant: KULANI IONGI 16836 SE STARK ST. PORLTAND, OR 97233 PHONE: 503-803-9316 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: C� Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12016-00151 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/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/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. 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 RECEIVE® City of Tigard JUL 19 2016 a PUBLIC WORKS —ENGINEERING _„T,{ ,._.. T IGARD — evf Public Facility Improvement (PFI) `Pei °` `NG TIGARD DESCRIPTION OF WORK(in the right-of-way) TYPE OF WORK Check one: tllity Connection ❑ TYPE 1–Franchise Utility Work Sidewalk/driveway approach Work performed by NWN,PGE ❑ Street improvements and/or utility agency. P�I Detailed description: 7OO 00 22C-u7-G,e 'TYPE 2–Sidewalk/Driveway/Sewer Work performed for the purpose of: • Sidewalk installation or repair. q [ • Driveway approach installation Property addddrress/location(s): 13 6 f 'S� L6 f'l and/or repair I v • Sanitary sewer lateral installation and/or main line tap c �r�� ❑ TYPE 3–Full scale Development Applicant: �� `� ' AJ ` Work performed with Land use s c y S r approval which includes any of Address: 1,6091361 /` the following: City/state: I ip: Z • Subdivisions or Partitions Phone: 3 'gd 3 ' 31kail: 6,n Gre es °y,-j®R A-4-T011- • Street widening Contact name: w-*# 1 Phone: SD 3 ' O 3 `%��6 • Mainline installation for Sanitary c sewer,Storm sewer,Tigard water Contractor: cp n off"ek J PLX P-- and/or Tigard Water Service.area CCB#: Z J O Z 3(& /Expiration: SUBMIT COMPLETED APPLICATION TO: Address: to f 3 6 S�' s � r City of Tigard City/state: 0�7CA''✓f� Zip7� 3 3 Planning/Engineering Phone:�� 3'$�3 'y3��:mail: o-�C r .� r /o+R,1 ,Com 13125 SW Hall Blvd. Tigard,OR 97223 � Contact name: Gt LVi Phone: SO 3 Applications for"minor work in right-of-way" only may be emailed to: ro"ermits atigard��or.g Engineer: Address: FOR STAFF USE' ONLI City/state: Zip: JJ�� / Phone: Email: Case No.: Az:l Q01&r a)s Contact name: Application submittal fee: f 3&0.06 Additional fees: Estimated value of work is required(if over$5,000):$ Application accepted: (within the public right-of-way) By: Date: - Application reviewed:. Is work related to a LAND-USE DECISION? ❑ Yes Df No ' By: K.F 1,14 Date: 7(/ If so,please specify (MLP,SDR,SUB, etc.) case #: Applicant notified: Is work related to a BUILDING PERMIT? ❑ Yes A No By: Date: 20 If so,please specify(BUILDING PERMIT) case#: I:\CURPLN\Masters\Land Use Applications Rev.07/09/2015 City of Tigard • 13125 SNX'Halll Bl Tigard,Oregon 97223 wwwtigard-or.gov 503-718-2421 Page 1 of 4 �' tb�-w 13' �/Z.E. CaA- � µD `'_ `vim- APPLICANTS NOTE: Person specified as "Applicant"shall be designated"Permittee"and shall provide financial assurance for work. 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. BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT: • The above request does not violate an),deed restrictions that may be attached to or imposed upon the subject prou4. • 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 the 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. SIGNA ES of each owner of the subject propertyrequired. 1 Ap ' ant/ thorized Agent's signature Print Aame 2� �u re Print narmc bate Owner's signature Print name Date Owner's signature Print name Date PUBLIC FACILITY IMPROVEMENT PERMIT Cityof Tigard • 13125 Six'Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov 503-718-2421 • Page 2 of 4 • DEVELOPMENT ENGINEERING FEES FOR STAFF USE ONLY Public Facility Improvement(PFI) Permit: DETAILED SUBMITTAL APPLICATION FEE REQUIREMENTS 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. (work in the right of way) Engineer's estimate X 5% (less$300.00 submittal fee) 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: There will be no permit fee charged,or assurance required FULL SCALE DEVELOPMENT for the following types of work: (Subdivisions/Partitions and Street Improvements) • Sidewalk repair(less than 20 lineal feet) • Relocate or replace mailbox Design Plans • Ditch cleaning that does not involve regrading. (G sets,24x36 or 22x34) • Weephole 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 • wwwtigard-or.gov • 503-718-2421 • Page 3 of 4 4 SAMPLE SKETCH: - SW 4)9y4)9 i Edge of Pavement I Ditch Streetlight I •------------- —r—•— x, /• G. o e ' T—propos d'Selw�r'Ti'ne" � � � I N� I 1 I .N Existing House Existing al1 :1 Driveway 3 I 1 (L Ial rl 01 � CF04® 1 a Tn a,iO ' Existing Shop � 0 Powerpole I I Y I a 95' I i --------7ropert 'Line----------- � I iI Fire Hydrant(FH) � � I Scale: 1"=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) PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard - 13125 SXX'Hall Blvd. - Tigard,Oregon 97223 - "mwtigard-or.gov - 503-718-2421 - Page 4 of 4 x Z� AWN a 141A i x h9fi i 40 COA/C2e7 FE —qPt /7