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PFI2018-00032 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT = COMMUNITY DEVELOPMENT Permit#: PF12018-00032 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 02/08/2018 Parcel: SEG2119 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: Premiere Concrete PFI Project Description: Remove and replace sidewalk @ 15350 SW OakTree LN Owner: FEES Description Date Amount PHONE: Contractor: PHONE: FAX: Applicant: LEX LEX PO BOX 230783 TIGARD, OR 97281 PHONE: 503-810-3752 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: See application Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12018-00032 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_SidewalkA 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/[ 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. PH 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 RECEIVED City of Tigard FEB 0 8 2013 PUBLIC WORKS —ENGINEERING Pubhc FacihtyImprovement TYPE OF WORK DESCRIPTION OF WORK(in the right-of-way) ❑ TYPE 1—Franchise Utility Work Check one: ❑ Utilities Side alk/driveway proach ❑ Streetimprove ents performed by NWN, PGE Detailed descri on. �f �CvL1t�(, ( and/or utility agency. TYPE 2—Sidewalk/Driveway/Sewer Work performed for the purpose of: / • Sidewalk installation or repair. Proper ddress/location(s): �y � � L,/✓ • Driveway approach installation and/or repair 1 d E C�, Zj I • Sanitary sewer lateral installation and/or main line tap El TYPE 3—Full scale Development Applicant: Work performed with Land use Address: approval which includes any of City/state: Zip: the following: Phone: Email: • Subdivisions or Partitions Contact name: A Phone: • Street widening • Mainline installation for Sanitary Contractor: �/r r� � �J, /�� sewer, Storm sewer, Tigard water v"'" ,.,�I�' and/or Tigard Water Service Area CCB#: ./Q�� Expiration: Address: PO Q V' d SUBAUT COMPLETED APPLICATION TO: �— City of Tigard City/state: Zip: Planning/Engineering Phone: ` mail: �.E'i'�. 01 G' � `¢f r �GT �1 13125 SW Hall Blvd. Contact name: Phone: Tigard,OR 97223 Applications for"minor work in right-of-way" Engineer: only may be emailed to: rowpermits_jigard-or.gov Address: City/state: Zip: rr �^ Phone: Email: Case No.: Contact name: Application submittal fee(.007%of Engineers Estimate) $ �-�-- Estimated value of work is required(if over$5,000):$ Additional fees: $ (within the public right-of-way) ApplicationcDate. tioon epted: f7 � 10 Is work related to a LAND-USE DECISION? ❑ Yes El No By 1� ' ' � Application reviewed: If so, please specify (MLP,SDR, SUB,etc.) case #: y: Date: Is work related to a BUILDING PERMIT? ❑ Yes ❑ No Applicant notified: If so,please specify(BUILDING PERMIT)case#: By: Date: CO2 h3118 I:\ENG\PermitApplications\pfi_application Rev.10/16/2017 CityofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page l of4 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 owner's signature on the application BY SIGNING BELOW,THE APPLICANTS) SHALL CERTIFY THAT: • The above request does not violate anyrecorded deed restrictions that may be attached to or imposed upon the subject 12rol2em. • If the application is granted,the applicant will exercise the rights granted in accordance with the terms and sub)ect 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 a � ant has read the entire contents of the application,including the policies and criteria,and understands the req em"ents for aper i7oyingr denthe application. Applicant/Authorized Agent's signature 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 PUBLIC FACILITY IMPROVEMENT PERMIT City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tlgard-or.gov 503-718-2421 • Page 2 of4 DEVELOPMENT ENGINEERING FEES FOR STAFF USE' ONLY Public Facility Improvement(PFI)Permit: DE'TAILED SUBMITTAL REQtTIREMENTS APPLICATION FEE Part 1: Required submittal fee$300.00 (minimum) FRANCHISE UTILITY AND SIDEWALK/ DRIVEWAY AND UTILITY PERMIT FEE CONNECTIONS,ETC. Part 2: All non-water system improvements (work in the right of way) Engineer's estimate X 5%(less$300.00 minimum Sketch submittal fee) (including information below) Engineer's estimate X 2°10 Plan Review ❑ Dimensions WATER SYSTEM FEE ❑ Street Name Part 3: All public water system improvements ❑ Site Address Engineer's estimate X 12% FULL SCALE DEVELOPMENT PFI Permit Fee Exemptions: (Subdivisions/Partitions and Street Improvements) There will be no permit fee charged,or assurance required for the following types of work: Design Plans • Sidewalk repair(less than 20 lineal feet) (6 sets,24x36 or 22x34) • Relocate or replace mailbox ❑ Cover—Site,Vicinity,Abbreviation,Legend • Ditch cleaning that does not involve regrading. ❑ General Notes(City,Water,Sewer,etc.) • Weep hole repair ❑ Street(Plan,Profile) • Curb repair or replacement(less than 20 lineal feet) ❑ Water,Storm and Sanitary(Plan Profile) • Lawn sprinkler system installation or repair ❑ Water duality Facilities • Street tree pruning or planting ❑ Grading • Planter strip landscape maintenance ❑ Landscaping/Tree Plan • Test wells ❑ Composite Utility Plan(Electrical,Phone,Gas, Storm,Sanitary,Water,Signage,Street Lights,etc) ❑ Details Note: A cash/bond assurance maybe ❑ Traffic Sight Distance required per TMC 15.04.140. ❑ Signing and Striping (customer deposit) ❑ Street Light Plan and Photometric ❑ Engineers seal/signature ❑ Sheet label(pro)ect 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 ofTigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 3 of4 r SAMPLE SKETCH: Edge of Pavement I I � Ditch Streetlight I —._.—.—.—.—.—.—r—.— '° Rdn btu Now ' 7" p'osewerTi'ne" a� Existing House Existi n g >fi Driveway c r ., ' zoi a I d'. L:GP dr, �I � I I Existing Shop Powerpole I I C �,� c3 • O I I 95' r Property Line " Fire Hydrant(FH) I I I I Scale: 'I"=30' � � I I I 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 ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 4 of4 E D FEB 0 $ 201g ,ARD PLIC, ,JEERING 1 f r -1 �•` K��' i i i I 1 v I f f i t i