PFI2017-00149 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
= COMMUNITY DEVELOPMENT Permit#: PF12017-00149
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 08/07/2017
Parcel: 1 S 134AD09300
Jurisdiction: Tigard
Site address: 10779 SW 106TH AVE
Subdivision: WINDSOR PLACE Lot: 30
Project: Baker Sidewalk Repair
Project Description: Replace 5'x 6'panel of sidewalk
Owner: FEES
Description Date Amount
PHONE:
Contractor:
JAY JACOB MILLER
8152 SW HALL BLVD#240
BEAVERTON, OR 97008
PHONE: 503-707-4725
FAX:
Applicant:
JAY MILLER
8152 SW HALL BLVD#240
BEAVERTON, OR 97008
PHONE: 503-707-4725
Total $0.00
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: � G•1
Issued By: A-A ' '
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12017-00149
Tv pe: 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/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.
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
RECEMED
City of Tigard AUG 0 3 2017
IIIUBI.[(.-. WORKS — I"NGINEFRING CITY OF TIGARD
rermit
Public Facillt-v JmprovernenpTrM,
DESCRIPTION OF WORK (in the right-of-way) TYPE OF WORK
Check one. 0 L'uhry('191ACCCUA
TYPE I—Franchisc Litility Work
SkIrwalk;drn-cw!y m)Ac h Work pc-rfovawJ Iw NWN,P(,E
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Sidcu-alk mstallawmk in rcpAps.
Drwem-A% ;ippn vach installmm
I't-operty addTC.i',/1,)c.4vnnwr 2ndl',)r repair
Sanitary scwer lateral!nst2flamin
...... . ........... andiijr main Jim tap
TNT E 3-Full scale Dcw1ofinkmi-,
,NpphCanT' ........... Work pericirmod with I.And UU,
Appmv;0 which inctudes 2nv or
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Zjp: Subdrvisions or Nrtmov%
Strw-Aidening,
pbe4ne: I mail,
Contact name: plione: ..........- NUnlinc installanor for Sinaary
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:Address: " City of Tigard
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Email: Ca No,:
Contact nanw %UbMAMI i0r.
[-."stimatcd value of vA)rk is required Iff over$5,(,XX I):S_ mcc"A
;within the public rigbt-of-u-ay) __4DL�
Applicauon rc%-xwr,&
Is-work related to a LUND-USF. DFCISI( )N; C, Yv�s '3-N,)
If so,pimse syct:6' (%41.P SDR, St-fi,etc.) carr #:
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Is work rclatrtl to a BUIDING PERNHT�, 0 N'c, Br lCi
PERMIT!case ti.
City ofTigard - 13125 SW I fall Bhd uwwrtgud-or.gov - 503.7118-2421 Page lqt'41
APPUC,ANTS
NOTE: larrson specified as"Applicant"shall tx:designatcd"13crmitti:c"and shall prmide financial assurance ft:rr vm)rlt.
Agra thr-a-v, 2no tfv sgp6irxnt arc Aiffrvx-m PoTk—,the 9,"-horst srius:,be tht past ha-cs of rrrtm!to. s kxart^to pmusamn atith wnttrn
20010nxnnrm fr+rrn.rilt ets t;,,Al sx,rrt-,.flat trxncr. 'l'... +:r+et{c;mist sign this ajV*,Ja(M in$x-PKC prtr!UW ut submit a wnmm
authsmntntss attia this,tppEra[nrxt
BY SIGNING BELONG,THE APPLICANT(S) SIULL CERTIFY THAT:
• if the appiieant?n ss granted,the applicant will caste ttie tate rights granted in accordanrc with the terms and subject to all the
coridim,>ns anti limitations 44 the appt4,va).
• U),-of thr ahtnv srarcmcnts and the summents in the plot ptar,attachments'and cxhibitc transmitted herewith,arc taut,and
the appixanrs sr,acknowitxiir that any permit issued,bared on this applicatinn,may be rc4oked if it is found that ant'such
statements arc false,
• The applicant has rva i the entire r—ontcras of the applicauon,incladtng the pc)tit:seS artd ctitena,and undcrhtands the
rccluircmcnte is-,r appro\,it4,r>r dcxrving the application_
SIGNA)rURES of ca-ch owner of the subject property required.
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pg�ltr lXit� usirrtl i rhi s ,t)�t,ature Print ttartr Date
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Owncr,s signaturt Print narnt.• Data
PUBLIC FAClUTN tMPROVE,,'1iEN7 PERMIT
City of Tigntrd 13122 SW i i;rli B)v(l. • Tigard,()rei;etn`i"'22-1 • ww w ngard orp)v 1,1)3-718-242) Pirge 2 ojf 4
1`"` EST EST NO,
Repair PROPOSAL ............
9peclialist
r;2 SW Had Bfivv,#;4,0 wipwaikrepairmaiLcom Plhorw,503-707-47?':
CCS# 198613
. . -te Trip Hazards
Property awne"are responsible for the repar,and maintei�6jire of the sjflPwA1,,8d*ent to their property,Avoid therzst,,dangers
and fias-Aes cof beim trw-4wd w,a tnp haz-ltd Lw^uit for persortal ifijuiy.'Your ne1qhbms,,chibw on Ncycies or Sicate�ards, new
mothem with barry carnages,disabied t>ecple in whep-4.haifs ami everyone e4sp haw one common need-A smooth,safe Mdewalk.
Let our experienced professionats grind out trip hazards or reptace sidewalk sections as needed.
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Buyet Signature- [tater.
Contraaor 54qnature- Date:
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Tigard,Oregon
Street View-Jan 2016
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