PFI2018-00017 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12018-00017
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 02/05/2018
Parcel: 2S111AC00600
Jurisdiction: Tigard
Site address: 14565 SW 91 ST AVE
Subdivision: PINEBROOK TERRACE Lot: 47
Project: Culbertson Sewer Replacement
Project Description: Adjacent to 14565 SW 91 st Ave. Replace sewer line from property to the street by means of hydraulic
bursting.
Owner: FEES
Description Date Amount
PFI Permit Fee 02/05/2018 $630.00
PHONE:
Contractor:
ENVIRONMENTAL WORKS LLC
2634 SE STEELE ST
PORTLAND, OR 97202
PHONE: 503-719-6715
FAX: 503-972-1866
Applicant:
DWIGHT CARLISE
2634 SE STEELE ST
PORTLAND, OR 97202
PHONE: 503-719-6715
Total $630.00
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: sG
Issued By: it'kyln'
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12018-00017
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/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/[ 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/[ 09-OTHER Applied Notice
V�Ec E::�\j ED
City o,f Tigard
JAN 2$ 218
pF_" ARS
PUBLIC 1N'()R1�S -- 1"NGINEERING p NNNG11�\!Ulv'EF_RING
Public Facifity Improvement FI Permit
17"PE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
�/ n TYPE I -- Franchise Utilil\ \\r,rl,
Check one: [ Utilities ❑Sidovalk/drivcway approach ❑Strectimprox-cments performed by NXX'N, 110
Detailed description: R-e (C sQ W\\ 'I and/or utilit}'agency.
n �'y Q I �_t TYPE 2–Sidewalk./Driveway/Sewer
CV I \�c,rk perfnrmed ii►r the purpose Of.
v4 rnr`� d r ��I ��tiJ�.l J f S•r �a Sidewalk installation or repair.
Sfi Driveway approach installati��n
Propert}' address/location(s): `��5�0 ��►`� yf and/or repair
• Sanitary-sewer lateral installation
and/nr main line tap
`_ \ El TYPE 3-- Dull scale Development
Applicant: ,n. 0n M �" UV C j W'rrrk performed with Land use
Address: nZ b 3`� 5 C �'f��I. � ` _ -^— approval xvhich includes any of
City/state: t`'n R L N Zip: U the following:
r
I n,a' ( C p M Subdivisions or PartitionsPhone:�,T�r b1 1� Email: rw�41� 1�j
• Street widening
Contactname: Car 1•�W Phone: 5 3 l ` -?
• Mainline installation for Sanitary
sewer, Storm sewer, Tigard water
Contractor:
and/or Tigard\Vater Scrvicc:arca
CCB#: i S ( Expiration: _
Address: 0SUBMIT COMPLETED APPLICATION TO:
Cita'/state: 17-1 p: _ City of Tigard
1 Planning/Engineering
Phone: Email: 13125 SDG'Hall Blvd.
Contact natne: Phone: Tigard,OR 97223
applications for"mitior work in right-.,f-m-Ay"
I�nglnCCr: Orkh•mas he cniAlcd ro:
rQ"crrnits .tigard_or.goV
Address:
FOR STAFF USE ONLY
Cite/state: "Lip:
Phone: Email: ease No.:
Contact Hanle: Application submittal fee(u of
Nigineer's F.stimatei S 6-30.Cep
Estimatedvaluc of w,o k is required(if over S5,000):S � GO Additional fees:
(within the public right-of-way) Application accepted:
By- Al� Date:
Is \vork related to a LAND-USI: DI C1S1()N;, ❑ 1•cs �91Nr,
Application rrt10,red:
If so, please specih.- (MIT,SDR,SUB, etc.) case #:
Br'� V• �_Date:
Is stork related to a BUILDING PFIRMM ❑ Yes �_N_ u Appficantnotified:
If so,please specify(BUILDING PERNIM case#: By: -hL--
I�ENG\PermrtAppBWdOrss�pti.application lNe:.wFltli:bil017
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • Nx mm-tigard-or.gov • 503-7,18-2421 • Page 1 of 4
APPLICANTS
NOTE: Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for work,if
required bN•the cite pursuant to Tti-IC 17.041.140.
With the exception of a utility operating pursuant to a valid franchise with the Cite of Tq ard.when the owner and the applicant are different
people,the applicant must be the purchaser of record or a lessee in possession Frith written authorization from the owncr or an went of the
owner. The owner(s)must sign this application in the space provided or submit a written nuthori-ratlon N%ith 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 Any recorded deed restrictions that may y be attached to or imposed upon the subject
rcn ,pert-.
• 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 anN-plot plan,attachments,and exhibits transmitted herew7th,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 dem7ng the application.
�\k �iv (_ -b� i U I < <L--1 S LC�
Applicant/Autho ized Agent's signature Print n111111e Date
SIGNATURES of each_o-vNner of the subject property, if required.
()Nvner's signature Print name Date
Owner's signature Print narne Date
Owner's signature Print name T Date
PUBLIC FACILITY IMPROVEMENT PERMIT
Citv of Tigard • 13125 Sok F lall Blvd. • Tigard,Oregon 97223 • www. igard-or.gtw • 50.3-718-2421 • Page 2 of 4
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'.045 65 145 70
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14595 14600
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146 14660
Environmental Works/Dwight Carlisle
2634 SE Steele Street
Portland,OR 97202
503.719.6715
dwight@eworksnw.com fA �t An
As required in
Off typical sections
Street Street of construction
Area plans
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6" Min bedding „
6
below outside of
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crushed aggregate
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2' Min Trench \\i\moi\\
foundation
stabilization
if required
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.
CITY OF TIGARD APPROVED BY. NO SCALE
OREGON MICHAEL A. STONE. P.E.
ENGINEERING DIVISION CITY o GINMR TRENCH DWG. NO.
PUBLIC WORKS DEPARTMENT
S.W.HALL BLVD.
TIG 180
TIGARD,OREGON 97223 JANUARY 2013 BACKFILL
VOICE:(503)6394171
FAX: (503)684-7297 APPROVAL DATE