PFI2017-00160 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12017-00160
13125 SW SEG1 Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 2017
Parcel: EG1351
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Delta Fire, Inc.
Project Description: 4"service for fire sprinkler system starting at 6 x 4 wet tap
Owner: FEES
Description Date Amount
Fire Service Connection-Base Fee 08/11/2017 $1,495.00
PHONE PFI Permit Fee 08/11/2017 $300.00
Contractor:
DELTA FIRE INC
14795 SW 72ND AVE
PORTLAND, OR 97224
PHONE: 503-620-4020
FAX: 503-620-1058
Applicant:
DAVID ASCHBACHER
14795 SW 72ND AVE
PORTLAND, OR 97224
PHONE: 503-620-4020
Tota l $1,795.00
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 `_ln
Signature: ZJr.�i �1�pLlC�
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12017-00160
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/[ 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/1 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/1 09-OTHER Applied Notice
RECEIVE®
City of Tigard AUG 0 9 2017
PUBLIC WORKS —ENGINEERING CITY OF TIGARD
■ P NNIN /ENGINEERING
Public FacilitY Im P rovement (PFI) Permit
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
❑ TYPE 1-Franchise Utility Work
Check one: '�; Utilities ❑Sidewalk/driveway approach ❑Streetimprovements performed by NWN, PGE
Detailed description: 4" Stvy•ieL -f-w P#&L and/or utility agency.
S Y S1W STAA&n J 4r Ar (.x4 W LT TAP. ❑ TYPE 2-Sidewalk/Driveway/Sewer
Work performed for the purpose of:
• Sidewalk installation or repair.
Property address/location(s): Z • Driveway approach installation
�lt�-�t�►t X99 4 �-• and/or repair
7 D o aw �r S
S*"-e-+. • Sanitary sewer lateral installation
and/or main line tap
Applicant: El 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:
bF LTA rrt RL, 1 x1 e- sewer,Storm sewer,Tigard water
and/or Tigard Water Service Area
CCB#: CA 174 Expiration:
Address: 14'?OLS S M/ 7 2 M 4 Xy t• SUBMITC01 MIMAPFUCATIONTO:
City/state: Pi0.T i_" D OA, zip: At 7 2 214 -79 S 2. City of Tigard
Phone:Sp3•G20.40ZOEmail: Planning/Engineering
13125 SW Hall Blvd.
C o)nttac`tnaame: U/W l t A SOLI ir►e!ffR Phone: So3.9 l •9 2 os Tigard,OR 97223
L*
7 1 Ss.'Lb(2!, PP • y
^�� Applications for minor work in t-of-wa
Engineer: 40N lact 0 only may be emailed to:
rowgemaits(a�yp�-or��ov
Address:
City/state: Zip:
Phone: Email: GWe No.r I -2 "r I tQCL
0
�.
Contact name: Application submittal fiv S 3C6•O0
Additional fees:S �ygs oC7
Estimated value of work is required(if over$5,000):$ P11A Application accepted:
(within the public right-of-way) Bjays .Date:
Application reviewed:
Is work related to a LAND-USE DECISION? ❑ Yes ❑ NoBy�G iS � Date: V110A 7
If so,please specify (MLP!,SDR,SUB,etc.) case#:
Applicant notified:
Is work related to a BUILDING PERMIT? 19 Yes ❑ No By. Date:
If so,please specify(BUILDING PERMIT)case#:F PS 2017.0,0108 1:\f"G\ft"^""opPc•"6^s\pfi-apo•tiDn Rev.17/16/2016
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-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 uti}ity operating pursuant to a valid franchise with the City 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 ownei s 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
prop
• 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
requirements for approving or denying the application.
4t^ a le-K64c.-i Ek 8-9-zmt-1
Applicant/Authorized Agent gnature 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
1
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
As required in
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NOTE:
1. 1' T—CUT FOR PIPE ONLY PROJECTS.
2. JOINTS TO BE TACK AND SANDED.
3. SAWCUT SHALL BE TACK COATED WITH BITUMINUS ASPHALT EMULSION.
CITE'<riF TIGARD APPROVED BY: NO SCALE
OREGON MICHAEL A. STONE, P.E.
ENGINEERING DIVISION TRENCH DWG. N0.
PUBLIC WORKS DEPARTMENT qTY ENGINEER
S.W.HALLBLVD.
TIG A O
TIGARD,OREGON 97223 JANUARY 2013 BACKFILL VOICE:
VOICE:(503)639-4171
FAX: (503)684-7297 APPROVAL DAIS
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