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PFI2017-00259 P TIGARD City of Tigard January 18, 2018 Black Rock Underground Attn: Drew McVey 267 NE 34`''Pl Hillsboro, OR 97124 Re: Permit No. PFI2017-00259 Dear Applicant: The City of Tigard has processed a refund for the deposit of fees on the above referenced permit for the following: Site Address: 13235 SW Ash Dr Project Name: Powers Job No.: N/A Refund: ® Check#227169 in the amount of$3,000.00. ❑ Credit card "return" receipt in the amount of$ ❑ Trust account"deposit" receipt in the amount of$ Notes: Refund 100% of customer deposit for work completed. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171 TTY Relay: 503.684.2772 0 www.tigard-or.gov a " City of Tigard Accela Refund Request This form is used for refund requests of land use, development engineering and building permit application fees. Receipts, documentation and the Request for PermitAction form (if applicable) must be attached to this request form. Refund requests are due to Accela System Administrator by each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts Payable will route refund checks to Accela System Administrator for distribution to applicant. PAYABLE TO: Black Rock Underground DATE: 12/28/2017 267 NE 34`h Pl Hillsboro, OR 97124 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 414276 Case#: PFI2017-00259 Date: 12/5/2017 Address/Parcel: 13235 SW Ash Dr. Pay Method: CreditCard Project Name: Powers EXPLANATION: Refund 100% of customer deposit for work completed. - 171 D INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Bu4joigg F.exmit.Vee Example: 234UQ00=43104 $Amount- Customer Deposit 100-0000-22000 $3,000.00 TOTAL REFUND: $3,000.00 APPROVALS: SIGNATURES DATE: If under$5,000 Professional Staff If under$12,500 Division Manager If under$25,500 Department Manager If under$50,000 City Manager If over$50,000 Local Contract Review Board FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY Case Refund Processed: Date: ZY By: I:\Building\Refunds\Refund Req uest.doc x 09/01/2010 i CITY OF TIGARD RECEIPT p a 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 r Project Name: Powers, Sewer Lateral Site Address: 13235 SW ASH DR Receipt Number: 416604 - 04/06/2018 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12017-00259 $-3,000.00 Total: $-3,000.00 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 227169 DHOWSE 04/06/2018 $-3,000.00 Payor: Black Rock Underground Total Payments: $-3,000.00 Balance Due: $3,000.00 Page 1 of 1 CITY OF TIGARD RECEIPT 13125 SW Ha►I Blvd.,Tigard OR 97223 503.639.4171 Project Name: Powers, Sewer Lateral Site Address: 13235 SW ASH DR Receipt Number: 414276 - 12/05/2017 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12017-00259 PFI Permit Fee 100-0000-43114 $410.00 PF12017-00259 Customer Deposit 100-0000-22000 $3,000.00 �— Total: $3,410.00 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Debit Card 031676 SCOPELAN 12/05/2017 $3,410.00 Payor: Andrew J McVey Total Payments: $3,410.00 Balance Due: $0.00 Page 1 of 1 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 14 Request for Permit Action !is 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • ww\y.tigard-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard, OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff Check(✓)one REFUND OR Name: 292A-C�� INVOICE TO: (Business or Individual) Mailing Address: ,2 '7" City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓): CANCEL/VOID PERMIT APPLICATION. REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). ❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit#: Site Address or Parcel#: Project Name: L�l Subdivision Name: Lot#: EXPLANATION: 4 Signature: Date: z2y-0�-ez7 Print Name. Refund Policy 1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of. • Any fee which was erroneously paid or collected. • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. • Not more than 80%of the application or permit fee for issued permits prior to any inspection requests. 2. All refunds will be returned to the original payer in the form of a check via US postal service. 3. Please allow 3-4 weeks for processing refund requests. 1`011 OFFICE' t!'SE' ONLY Route to Sys Admin: Date By Route to Records: Date B Refund Processed: Date/L12,foh 2 B Invoice Processed: Date B Permit Canceled: Date N B —Parcel Tag Added: Date B I:\Building\Forms\RegPermitAction_ 92314.doc CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit ft: PF12017-00259 r 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 12/05/2017 Parcel: 2S 102CA00210 Jurisdiction: Site address: 13235 SW ASH DR Subdivision: VIEWCREST TERRACE Lot: 8 Project: Powers, Sewer Lateral Project Description: Address 13235 SW Ash Dr. Tax Lot ID: 2S102CA00210. Pipe burst replace the sanitary sewer lateral from the home to the PVC transition on the street. Owner: FEES Description Date Amount PFI Permit Fee 12/05/2017 $410.00 PHONE: Customer Deposit 12/05/2017 $3,000.00 Contractor: PHONE: FAX: Applicant: DREW MCVEY 267 NE 34TH PL HILLSBORO, OR 97124 PHONE: 503-828-4790 Total $3,410.00 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. i Permittee/Applicant / Signature: '7 Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12017-00259 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/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/1 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 HLU1=1VLU City of Tigard N O V 9, 0 2017 e PUBLIC WORKS — ENGINEERING CITY OF TIGAR® "rGiENGIW EKING errni Public FacilityImprovement P TYPE OF WORK DESCRIPTION OF WPRK(in the right-of-way) ❑ TYPE 1-Franchise Utility Work Check one: ❑ Utilities J�Sidewalk/driveway approach ❑ Streetimprovements performed by NWN, PGE �► Detailed description: e, bqrsk "-4"d/or utility agency. 1 TYPE 2-Sidewalk/Driveway/Sewer r � Work performed for the purpose of: • Sidewalk installation or repair. 13 -30 5� � • Driveway approach installation Property address/location(s): 7 and/or repair T9K VID ' 2y 101c oZ1 • Sanitary sewer lateral installation and/or main line tap A licant: �(�, 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 • Street widening Contact name: c, Phone: 1 • Mainline installation for Sanitary Lsewer, Storm sewer, Tigard water Contractor: ��L a �-� and/or Tigard Water Service area CCB#: Expiration: Address: SUBMIT COMPLETED APPLICATION TO: City/state: Zip: GL City of Tigard Phone:563•1 S.L09 b Email: �o Ac 0C.0k%3TU� �o c h Planning/Engineering �/� ``SS l� a r a.f'� ° 13125 SW Hall Blvd. Contact name:1� W 1 � (N g�A Phone: !fyAVV►eTigard,OR 97223 ?applications for"minor work in right-of-way" Engineer: only may be emailed to: rowMermits(ktigard-or.gov Address: FOR STAFFUSE ONLY City/state: Zip: Phone: Email: Case No.: �F��{ Contact name: Application submittal fee(.07%of Engineer's Estimate) $A9:SMP= Estimated value of work is required(if over$5,000):$ �T Additional fees: $ (within the public right-of-way) Application accepted:Date: qq �- �l'Z� Is work related to a LAND-USE DECISION? El Yes El No By: S If so,please specify (MLP, SDR, SUB, etc.) case #: Applica ' n re wed: `� By: Date: -a-W-17 Is work related to a BUILDING PERMIT? ❑ Yes ❑ No Applicant notified: If so,please specify(BUILDING PERMIT)case#: By: Date: V�--LH_7 I:\ENG\PermitApplications\pfi—application Rev.10/16/2017 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 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 owners signature on the application BY SIGNING BELOW,THE APPLICANTS) SHALL CERTIFY THAT: • The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject proper • 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 requirem s for pproving or denying the application. C e 1 Zd Apk�ca uthorize Agent' e int Dna Dat SIGNATURES of each owner of the subject property, if required. —Ece 440IJ CW , Im^7 G Rk d) I V Ldl 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 DEVELOPMENT ENGINEERING FEES FOR STAFF USE ONLY Public Facility Improvement(PFI)Permit: DETAILED APPLICATION FEE REQUIREMENTS Part 1: Required submittal fee$300.00 FRANCHISE UTILITY AND SIDEWALK/ PERMIT FEE DRIVEWAY AND UTILITY CONNECTIONS,ETC. Part 2: All non-water system improvements (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: FULL SCALE DEVELOPMENT There will be no permit fee charged,or assurance required (Subdivisions/Partitions and Street Improvements) for the following types of work: • Sidewalk repair(less than 20 lineal feet) • Relocate or replace mailbox Design Plans • Ditch cleaning that does not involve regrading. (6 sets,24x36 or 22x34) • Weep hole 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 ❑ Engineer's Construction Estimate , . . PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 3 of 4 • SAMPLE SKETCH: Edge of Pavement I � Ditch Streetlight I ----------------r---- cmI ' lr 'rro'pos d�Se1�werTine'a I % 1 14 Existing House 1 Existi n I g Driveway . CI R I ;ter 09 I ` aCFA I 1 > CCI 1 >I ° I Existing Shop 1 C" - Poerpole I = I a CD o . a 95' 1 I I --------rrop 7i L7in � I so I I Fire Hydrant(FH) � I I Scale: 'I"=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 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2421 Page 4 of 4 RM*Urdergmnd'-Ga-C -Esfff nate 267 KE 34th Place CCB# 196119 Hillsboro,OR 97124 US (503)747-9312 infD9blackrockunder-ground.com I'l-ti'P:I/wvnv.black,rockundergrour�.oc.m ADDH66S -SHIP TO Paul Packer Paul Packer 13235 SW Ash Dr 13235 SW Ash Dr Tigard?OR Tigard,OR ESTIWTE# DATE 1789 08/01/2017 ACTIVITY AM01UNT 14 PlumWng:ExtederF1jmtft:EAsAar FlumtArT.-f B" 1 5,870.00 5,870.00 W1's&est 0 mn@ Pen To provide all labor,equipment, material and permits to pipe burst replace the sanitary sewer laterai from the cast iron transition at the home to the Citi of Tigard sanitary sewer in the street. - Excavate to access the cast iron transition at the home. -Saw cut,jack hammer and remove a portion of ft aspha-ft in the street to gain access to that sanitary seweT- -All excavated material in the street will be removed. hauled off and disposed of properly. - Pipe burst replace 4"HDPE pipe from the home to the city main. - Import crushed rock,back M1 and compact in place in the street. - Re pave and re sea!the portion oi, rermovsd asphalt. - Back fill and compact the excavated area at the hoirie- -All work and material provided will conform with City of Tigard standard specification - Due to the cast iron transition being located near the Japanese maple tree. It is recornmended that tme lhome ai�mer remove the tree for transplanting prior to the project. Biack Rock Underground, LLC is not liable for survival of the landscape, trees or shrubs_ RECEIVED NOV 2 0 2017 CITY OF TIGARD PLAN NIM117_1 NIC 7 ER ING ACTIVIT'y OXY P A,-J, AMOUNT Me 0.00, , -Spedft DetEds If proper grade cannot be acNeved within the footage stated above, additional excavation may be necessary ar-,,,d a mange order may be issued. Asphaft patching will take place at a fime to be determined after the sewer excavation has been completed and weather permitting. Bid had been issued prior to any public utility iocated and if any public utilities are located in the excavation area, addiflonai'wand tugging"to expose these utilities may be necessary and a change order for additional labor may be issued- Bid includes any traffic control plans, no parking permits,traffic control eqwpment and signage, street Oating,and traffic permits that may be required. We wP!attempt to avoid damaging any additional hard surfaces in the excavation area, but if any additional surfaces are damaged during the excavation process, a change order may beissued_ Wamuq 1 0.00 0.00 10 year Warranty:Work includes a 10 year transfer-abie warranty on all workmanship performed by Black Rock Underground, LLC and is guaranteed to provide a serviceable sewer line on the portions of the line instalied by Black Rock Underground, LLC that rneets at.'local plumbing codes. Warranty excludes any uncontrollable acts of nature. RECEIVED NOV 9, 0 2017 CITY OF TIGARD PLAN NING/ENGINEERING RATE AMOUNT ural Tems and and se 0.00 0.001 1. SCOPE OF WORK. Black Roc:Underground, LLC ("Contractor')shalt tuA nis'h ali tabor,super-Asi+on, nnalkeriais, equipment, tools and supplies necessary to complete the repair,remediation and/or improvements as set forth in the attached proposes)and in any drawings and specificabons incorporated into the proposal(the"'Mork").The work small be performed in a professional and workman like manner. Contractor may,at its discretion,engage licensed subcontractors to perform portions of the Work. Contractors shall not be liable to perform,or iiable for damages arising out of,works that is excluded from the Work Estimate and./or wofk that is performed by a separate contractor pursuant to a direct contract between Owners and such separate contractor. 2. UNIFORSEEN CONDITIONS/CHANGE ORDERS. Contractor wixl be compensated as a result of a change in the scope of Work that increases costs through a written Change Order, which may also increase the contract time. Contractor shall not proceed with changes in the scope of Wcrk(either additions or deletions) without a Change Order by, signed by Owner and stating the des--nption of work for the change and additional cost. 3. PERMITS. Upon notice to proceed, Contractor shall obtain all required permits to perform the Work. Contractor shall comply with all applicable codes,safely ordinances, local,state and federal laws applicable to or related to the Work. 4. PAYMENT. Payment is due in full at the time servicers are completed. A:late charge of 1.5%monthly(18%APR)will be applied to all past due accounts.This is a fixed cost bid based upon the scope of work described herein. 5. AUTHORIZATION OF WORK.Authorization to proceed-11 the undersigned. am owner/authorized representative¢°tenant at the premises at whi.-h the warfc rrtenEioaeid is to be done.I hereby authorize €Mack.Rock Underground, LLC and its affiliates to perform the Work. I have read this contract, including tlw€e terms and conditio.-6 and agree to be bDund by all the terms contained herein. I have received a copy of this contract and required notices for residential construction projects. TOTAL Accepted By '� � � Accepted Date 11/10/18 RECEIVED NOV 9, 0 2017 CITY OF TIGARD PLANNING/ENGINEERING ► � 0 3 23 Sw Asti �� .ac � - E �_ — � . TI GARP OtZ `�1'2-23 � . `�. � - -- _ �-�.� -,.�- _• ' -- --.�-�-_�-.. r,�.a-�c-_•n..,.':.��.:_:,+�YOrY1r�'iY<.��;.urraa::..i.M_�a'�-�.:' l �+WaaWaea��.A�.r-.+-.— r.•:ts:--�:.ia:_•e-+s.r:>-.,eat Ii C/o � Geo .�,�.�...�.. VAo J ^4f?,'Wir�i•�+R-,�1:,.�r,,.<=.. sae. =`m•a_-x- -_ - :*�"�",'•��+.' jcf* T .r Fo I STC -, • Ii�(-.A",,,:�'xan,�'�'•c_ -- e�'•• -�. -.- - -..®...,:a-�sr�w-a ,.;.p,.,+y wF,q....�a RECENED 30� wE-•-�R::�tr�:-.,Q a _ '`._ae..rK��.e=..ate• `R'.;,-c;.•'"•'�,.;..'Y"'-= M ♦ic.lell�eYeeaeW�i1 1�dOlr4.�.ae3�s ��v'�'�•;��TI�:C�-�JNt'�..�i1��i�..J'AlY 1�-Y'L'SA:�:�'.a-.tc NOV 2 0 2017 CITY OF TIGARD PLANNING/ENGINEERING