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PFI2018-00021 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT = COMMUNITY DEVELOPMENT Permit#: PF12018-00021 f 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 02/01/2018 Parcel: SEG2506 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: 93rd ave Sewer Break Project Description: Repair the sanitary sewer lateral Owner: FEES Description Date Amount PFI Permit Fee 02/01/2018 $300.00 PHONE: Contractor: PHONE: FAX: Applicant: DREW MCVEY 267 NE 34TH PL HILLSBORO, OR 97124 PHONE: 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 Issued By: --�— Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12018-00021 Type: Condition Name: Status: Severity: PFI_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 05-TRAFFIC CONTROL SPECIFICATIONS Applied Notice Applicant shall provide traffic control according to the current edition of the"Manual on Uniform Traffic Control Devices [MUTCD]for Streets and Highways", U.S. Dept. of Transportation, FHWA, current edition,American Traffic Safety Services Association[ATSSA], and Oregon Temporary Traffic Control Handbook[OTTCH]. PFI_Utilities 06-TRAFFIC CONTROL PLAN Applied Notice Submit a job specific traffic control plan. A copy of the approved traffic control plan shall be readily available at the work area. Traffic control devices, flag persons, etc., shall be in place prior to initiation of construction work and shall be effectively maintained. PFI_Utilities 07-TRAFFIC CONTROL ROAD CLOSURE Applied Notice Public roadway shall not be closed to traffic, at any time,without obtaining written approval from the City Engineer. The applicant is responsible to provide 48 hour advance notice of traffic flow disruptions to affected businesses, residents and area wide Emergency Services: 503-629-0111 (Tigard Police Dept., Tualatin Fire&Rescue)and to 503-962-8140(Tri-Met) and 503-431-2345(Tigard School District)and other service providers impacted by such closure. PFI_Utilities 08-TRAFFIC CONTROL PROPERTY ACCESS Applied Notice Access to existing properties shall be maintained at all times, including normal delivery service and mail service. Obtain City approval of any access closures. PFI_Utilities 09-TRAFFIC CONTROL WORK HOURS Applied Notice Work is permitted in daylight between the hours of 7:00 a.m. to 7:00 p.m. Mon-Fri unless otherwise authorized by the City. PFI_Utilities 10-TRAFFIC CONTROL LIMITED WORK HOURS Applied Notice Hours of construction work on collector and arterial roads will be limited to 9:00 a.m.to 3:00 p.m. unless authorized by the City Engineer. Work will not be permitted on collector and arterial roads between 3:00 p.m.to 9:00 a.m. unless authorized by the City Engineer. PFI_Utilities 11 -TRAFFIC CONTROL MODIFICATION Applied Notice The City reserves the right to add to or modify traffic control requirements as necessary to effectively control traffic and to assure public safety. PFI_Utilities 12-UTILITY NOTIFICATION Applied Notice Oregon law requires following the rules adopted by the Oregon Utility Notification Center. Said rules are set forth in OAR 952-001-0100 through OAR 952-001-0080. Copies of said rules may be obtained from the Center by calling 503-246-1987. If you have any question about the rules, contact the Center. NOTE: Damage to utilities shall be corrected at the permit holder's expense. PFI_Utilities 13-UTILITY LOCATION CONFLICT Applied Notice Applicant must verify all existing utilities for both vertical elevation and horizontal location prior to start of work(pothole before digging if necessary). Should conflicts arise and redesign or relocation of facilities be necessary, it shall be done at the applicant's expense. Changes must be approved by the City in advance of work.Applicant shall coordinate the work with affected utility agencies. PFI_Utilities 14-TEMPORARY PATCH Applied Notice A temporary hard-surface patch shall be placed on trenches within roadways at the end of each work shift. Obtain advance approval of patching method. No trench shall be left at any time in an un-safe condition. Applicant is responsible for and is liable for hazards or damage resulting from the prosecution of the work. PFI_Utilities 15-REPAIR OF EXISTING FACILITIES Applied Notice Work under this permit shall include repair of existing facilities(roads, ditches, etc.)as may be necessary, as determined by the Inspector, to overcome deterioration or damage which occurred in conjunction with the work authorized by the permit. Corrective work shall be done at the applicant's expense. PFI_Utilities 16-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_Utilities 17-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_Utilities 18-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_Utilities 19-MONUMENT PROTECTION Applied Notice Existing monuments, property corners, and survey markers shall be protected. Replacement shall be at the permit holder's expense. PFI_Utilities 20-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_Utilities 21 -OTHER Applied Notice . RECEIVED City of Tigard FEB 12018 1 Pt'BI.IC WORKS — 1;NGINEERING CITY OF TIGAMD . PLAN NTNG/EN INEERING TIGARD 11 tY Public Facili Improvement PFI erml TYPE OF WORK DESCRIPTION OF WORK(in the right-of-way) ❑ TYPE 1—franchise Utiiitt-11'urk Chcck one:/t"tilitics ❑Sidewalk/driveway approach ❑Strcetilnprovements performed by N\t'N, P(1 L? Detailed description: S A eC' and/or utility agency. TYPE 2—Sidcxvalk/Driveway/Scwcr \x'ork performed for the purpose of- - f• SidcNvalk installation or repair. / O. Q � 5� �n�� Dri�-ewa�•approach installation Property address locations ` 1`� ! and/or repair a • Sanitary sewer lateral installation and/or main line tap ❑ TYPE 3—full scale Development Applicant: Work performed with Land use Address: approval which includes any of City/state: Gih: the following: Phone: l;mail: • Subdivisions or Partitions Contact name: Phone: • Street widening • Mainline installation for Sanitary 1 L sewer, Storm sewer, 'Tigard water Contractor: ACA L and/or Tigard\Vatcr Servicc.Arca CCB#: I C11(D V3 Expiration: Address: `'l� � IDA SUBMIT COMPLETED APPLICATION TO: City/stare: �] \lS e�(`c� �- Zip: �L� City of Tigard Phone: �'!► g'L$•L4100 Planning/Engineering 13125 SW Hall Blvd. Contact name:1-- Phone: Tigard,OR 97223 :Applications for"minor-\vork in right-of-way" Engineer: only may he emailed to: romTe rmitsLa-,tii;ard-or.gov Address: FOR STAFF USF ONLY City/state: Zip: Phone: Email: Case No.: CPT 2 - 0 Q O `2 Contact name: Application submittal fee(.07%of t Engineers Estimate) $ Estimated value of work is required(if over$5,000):$ 5 k Additional fees: $ ,3 Q(7 (within the public right-of-way) Application accepted: Is work related to a LAND-USE DECISION? ❑ Yes El No B,•: ryl 6 Date: If so,please specif�r (MI-P,SDR,SUB,etc.) case#: Application reviewed: / By 0 Dat, ` Is work related to a BUII..DING PFRNIIT? ❑ l'cs ❑ No Applicant notified: If so,please specify(BUILDING PERNIFJ' case#: BN Date: Date: I:\ENG\PermitApplications\pfi application Effective 10/16/2017 :'>"��t4RtiSF 1aY:q&:Y.M1k-YtiW.`•i:4�i'£<-,i&Sf'T�:rX i`t1gn.;1:94�if..k.5f*�'kk:'SSC*2'•Sm�5A.4'F.r M,,,.;13E»�tai,.rR3:e4rv.'i'e$.�h;-..i-- .Sam.e•e.aNu.U'a5$..,5,�°v.i4,.�h'ir`3zRh'lr$dsh+ P.N.. a"5��._°_^_T�.n,v M,.°�C.J..R+.52g?:v."=n+ ";Sv.y'.941S 4xA�Y.,-e �'ki'k"a3A4.kS.�,G, ,`.�...�£x�+'.'- -"#.?'r•S?t .'�'�.&Sb" City of Tigard 13125 SW f1all Blvd. • Tigard,Oregon 97223 • %x,,v-\v: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 TM(-' 15.041.140. \Vith the exception of a utditN'operating pursuant to a valid franchise with the Cin-of Tigard,when the o-,vner and the applicant are different people,rhe applicant must be the purchaser of record or a lessee in possession with written authorization from the owner or an agent of the owner. "I'hc owner(s) must sign this application in the space provided or suhmit a written authorization with this application. Franchised Utilities are not required to obtain the owner's signature on the application BY SIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT: • The above request does not violate ariv recorded deed restrictions that matt be attached to or imposed upon the subject ro er •. • 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 ant•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 ap lication. Zol�3 icant/ orized Agents snatu Print name Da SIGNATURES of each or of the subject property, if required. 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 97-123 • w-vt-w:tigard-or.gov 503-718-2421 • Page 2 of 4 DEVELOPMENT ENGINEERING FEES FOR STAFFONLY Public Facility Improvement(PFI)Permit: DETAILED SUBMITTAL REQUIREMENTS APPLICATION FEE Part 1: Rc(luircd submittal fee$300.0(1 FRANCHISE UTILITY AND SIDEWALK/ PERMIT FEE DRIVEWAY AND UTILITY CONNECTIONS,ETC. Part 2: All non-water system improvements (work in the right of wa)) EnPricer's estimate X 5`Yo(less S300.00 submittal fee) l ngincer's estimate X 2%Plan Review Sketch (including information below) WATER SYSTEM FEE ❑ Dimensions Part 3: 1111 public water system improvements ❑ Street Name Engineer's estimate X 12%� El 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 (G sets,24x36 or 2234) • Ditch cleaning;that does not involve regrading. • Weep hole repair ❑ Cover--Site,Vicinity,Abbreviation,Legend • Curb repair or replacement(less than 20 lineal feet) ❑ General motes(City,Water,Sewer,etc.) • l_aNvn 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 • 'fest wells ❑ Grading ❑ Landscaping/Tree Plan ❑ Composite Utility Plan(Electrical,Phone,Gas, AStorm,Sanitarn,Water,Signage,Street Lights,etc) Tote: A cash_ assurance may he requiredper TALC 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 black,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.tig;ard-or.gov • 503-718-2421 • Page 3 of 4 SAMPLE SKETCH: r C Ed-le of Pavefnez-A Ditch r F-'.:LnL ET:Int 7 -7roT)'—0 S– m4wel-ri-117— t4 Existinrl House t'l I Existing i • Driveway 1 X11 LL 01 111. 1 Existing Shop F, I L5 CL_ ToIpTrfty-L 7ne--—- — - — - — - — - Firms Hy drri t i F H MINIMUM SKETCH REQUIREMENTS (Put'IN/A"if Not Applicable): North arrow Property lines &dimension Slope of proper�� 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 - wwwtigard-ongov - 503-7118-2421 - Page 4 of 4 Location: 727,5- sw r trA/ Dom., Name: YNR Date: I-Z2 -Zojg 7 2,2, CAP0165f: Point of Access: 30" airs elo Pipe Type: 44 owc 3 ,ass — 1 cavC. Depth At Home: l � Z Depth At Main: pip mo-r RrAdl � Machine Access: 4P N 0 Roots 0 Pooling g 0 Off-Sets c �510, Repair Type. S Length of Repair: Z® ' A4 L e Note : 1`0 ha. K Ssu tAll o, L 1W O �L�Ad1 Q CITY OF TIGARD RECEIPT S 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 Project Name: 93rd ave Sewer Break Site Address: Receipt Number: 415369 - 02/01/2018 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12018-00021 PFI Permit Fee 100-0000-43114 $300.00 Total: $300.00 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 01021d MBILODEAU 02/01/2018 $300.00 Payor: Andrew Mcvey Total Payments: $300.00 Balance Due: $0.00 Page 1 of 1