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PFI2018-00129 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12018-00129 R 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 06/04/2018 Parcel: 2S111 DI309400 Jurisdiction: Tigard Site address: 15565 SW OAKTREE LN Subdivision: SUMMERFIELD NO.10 Lot: Q Project: Wilcox Driveway Replacement Project Description: Replace driveway and existing approach Owner: FEES Description Date Amount PFI Permit Fee 06/04/2018 $300.00 PHONE: Contractor: PHONE: FAX: Applicant: LEIGH WILCOX 15565 SW OAKTREE LANE TIGARD, OR 97224 PHONE: 503-329-5856 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 t' Signature: Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY I I Conditions for PF12018-00129 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/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/1 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/[ 09-OTHER Applied Notice 'ECEI V City ®fTi and MAY 312018 PUBLIC WORKS -- ENGINEERING CiTy OI-P F _Ai`�i�iilvC�/��'��:� � Fadhty errmt TYPE OF WORK DESCRIPTION OF WORK(in the right-of-way) ❑ TYPE 1-Franchise Utitiry)Vork Check one: ❑ Utilities E Sidewalk/driveway approach ❑Streetimprovements performed by N©NT , PGE and/or utility agency. Detailed description: kaQw_�?'e' d V"i W `� t i ! ❑ TYPE 2-Sidewalk/Driveway/Sewer Work performed for the purpose of Sidewalk installation or repair. .-, s ° Driveway approach installation Property address/location(s): � �,� • � �' and/or repair �Q- T\'Q' 0-d ° Sanitary sewer lateral installation and/or main line tap El TYPE YP'E 3-Full scale Development Applicant: I,P� SIV 1 Work performed with Land use Address: h r �J. approval which includes any of City/state: i a-rd Zip: �'�� the following: Phone: � Email: ��(1Ctb'`-l�ep?�h��C-_o4 i1Cyime t1C� Subdivisions or Partitions J Contact name: LE'_t C, h Phone: ZD3 _3�1_61zCe l� Street widening Alainline installation for Sanitary Contractor: t.-� /°u_ ! k v\ova-� l sewer, Storm sewer, Tigard water +�- V i�� CCB#: 06( and/or Tigard.Water Service area ' Expiration: -T Address: . Eng o=3 SUBMIT COMPLETED APPUCATdoNTo: City/state: .t31-?6 J&r40y-\ Zip: q 90017 City of'Tigard Phaning/Eagr�neerbW Phone: t� �(�.(gWEmail: t l-l to oy cu i c'it S ALL 3C' �"ri 13125 SW><-Ia]1 Blvd. Contact name: PeA n Phone: 'Tigard,OR 97223 Applications for"minor work in right-of-quay" Engineer: only may be emailed to: row�erwits,�.tigard-or.gov Address: City/state: Zip: r1 pp 2ld Phone: Email: Case No.: P120- V 0! Contact name: Application submittal fee(.007%of Engineers Estimate) $ Estimated value of work is required(if over 5,000): 1, 4 =dditional fees: $_ . -*z19 E (within the public right-of-way) Application accepted: Is work related to a LAND-USE DECISION? ❑ Yes R(No By: S� Date: � If so,please specify (MLP,SDR, SUB, etc.) case#: Apphca 'on reviewed: 3y: Date: Is work related to a BUILDING PERMIT? ❑ Yes Rf No Applicant notified: If so,please specify(BUILDING PERMIT)case#: B}r:___MZ' Date: 1:NENGtPermit4phcations\pfi_application Ren.10/16/2017 City of"Tigard 13125 SW Hall Blvd. ° Tigard,Oregon 97223 ° www tigard-or.gov o 503-718-2421 m Page 104 AI�PLICAIl TS NOTE: Person specified as "Applicant"shall be designated"Permittee"and shall provide financial assurance for work,if required by the city=pursuant to TMC 15.441.144. * 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) SHALT.CERTIFY THAT: o The above request does not violate any recorded deed restrictions that may 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 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. Lei � - �- l Applicant/Aut rued Agent's signature Print na e Date SIGNATURES of each owner of the subject property, if required. Lerch kl VJ I�Cox 5-26(- 12 Owner's si a. e Print nazrLe Date Owner's signature Print name Date Owner's signature Print name Date PUBLIC FAryC-+In-pLry=xYyIMPROVEMENT "_M.�' "`"��.. eersF.x .vnmca��•.�ar PERMIT City olTigard a 13125 SW Hall Blvd. - Tigard,Oregon 97223 a wwwtigard-or.gov s 543-718-2421 Page 2 of4 ,. ......., . ._ h.g..,4•'H- ., li. _. ^•-r-.v :9C:.. T"..x'--s .- '.,T t..',N a• f )..�`�'. ,C,, �� q n.... V 4, 91:+:I�S �F. e�jh'[.h`, w++-' '~Mem^u�-,.::..1.. �r^`:.e Ha�, y.'�iy,VSA�, e.4a a n'rY! .ST - , .A,.d Sa _ ,_ k 1:,..fj ..f.',... 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