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PFI2018-00165 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT ® COMMUNITY DEVELOPMENT Permit#: PF12018-00165 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 07/02/2018 Parcel: 2S1036610000 Jurisdiction: Tigard Site address: 12060 SW 122ND CT Subdivision: YE-OLDE WINDMILL Lot: 21 Project: Palacios Sewer Replacement Project Description: Replace sewer line in ROW, located at 12060 SW 122nd Court. Owner: FEES Description Date Amount PFI Permit Fee 06/28/2018 $300.00 PHONE: Contractor: PACIFIC GENERAL CONSTRUCTION LLC PO BOX 220179 MILWAUKIE, OR 97267 PHONE: 503490-7727 FAX: Applicant: JOSE HERMANDEZ PO BOX 220179 MILWAUKIE, OR 97267 PHONE: 503490-7727 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: Issued By: 4to� Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12018-00166 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/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/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/[ 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 1. mECEIVED Cit ofTigard JUN �� 201 ` `asCITY OF TIGARD PUBLIC WORKS — ENGINEERING Ell ° PLPLANNING/ENGINEERING Public FacilitvIml-%rovement (PFI) Permit TYPE OF WORK DESCRIPTION OF WORK(in the right-of-way) ❑ TYPE 1-Franchise Utility Work Check one: ❑ Utilities ❑Sidewalk/driveway approach ❑ Street improvements performed by NWN, PGE Detailed description: /and/or utility agency. LTJ TX1<'E 2-Sidewalk./Driveway/Sewer i' `A L-o-- s4�✓ �' �Y�-- 032 D 1.�� Work performed for the purpose of- Lay £ Lay ° Sidewalk installation or repair. h ° Driveway approach installation l,; Property address/location(s): 1 ltd Q iV`�d' 1� and/or repair ° Sanitary sewer lateral installation and/or main line tap El TYPE 3-Full scale Development Applicant: Work performed with Land use Address: 120 15 W 1.2 2- C4y " approval which includes any of City/state: ��wz-c+—1�- d)c Zip: l z-)-,7 �� the following: Phone: _�`Pray "77-0 Email: ° Subdivisions or Partitions Contact name:�V �-- Phone: ' p7 �..� ° Street widening L-5- � ° Mainline installation for Sanitary L Contractor: - C_ L L C_ sewer, Storm sewer, Tigard water and/or Tigard Water Service Area CCB#: L/2_ C� Expiration: Address: ��o 5th ! ..0 SUBMIT CONYPLETEDAPPLICATION TO: City/state: Y,-j YN Zip: .22 3 City of Tigard Planning/Engineering Phone:2,2-? t,7 ci d '7 22 Email: L . I-L L j;j2e JW "�,, `1.e � T ' _ avti 13125 SW Fall Blvd. Contact name. 9 Yt• Phone: .!q& V!&d 7-7Z,7 Tigard,OR 97223 Applications for"minor work in right-of-way" only may be emailed to: Engineer: romTermitsCa�r�tigard-or.gov .Address: gem 1°E"un Oo lily City/state: Zip: . Phone: Email: Case No.. 1 �_ Contact name: Application submittal fee(.007%of Engineers Estimate) $ Estimated value of work is required(if over$5,000):$ o�eb Additional fees: $ - ' (within the public right-of-way) �Q Application accepted: Is work related to a LAND-USE DECISION? [I Yes El No By: Date: �5 If so,please specify (MLP,SDR, SUB, etc.) case #: Application reviewed: f By: Date: Is work related to a BUILDING PERMIT? ❑ Yes ❑ No Applican notified_: F If so,please specify(BUILDING PERMIT)case#: By: Date: 2, l:\ENG\PermitApplications\pfi—application Rev.10/16/2017 City ofTigard ° 13125 SW Hall Blvd. ° Tigard,Oregon 97223 www.tigard-or.gov a 503-718-2421 o Page 1 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 Nvith this application. Franchised Utilities are not required to obtain the owners signature on the application BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY'I1 AT: • The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject property. • 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. Appli nt/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 PIERMTIC City ofTigard o 13125 SW Hall Blvd. ° Tigard,Oregon 97223 ° www.tigard-or.gov 503-718-2421 ° Page 2 of4 DEVELOPMENT ENGINEERING FEES q MB @U&W un emu ]Public Facility Improvement(PFI)Permit: APPLICATION FELE V 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 submittal fee) Sketch Engineer's estimate X 2%Plan Review (including information below) ❑ 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: Resign 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 Quality.Facilities. • Street tree pruning or planting ❑ Grading • Planter strip landscape maintenance ❑ Landscaping/Tree Plan. ° Test wells ElComposite 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(project land use name,revision and plan log block,dates and sheet numbers.) Ad& onal Submittals (per Land Use conditions) 0 Traffic Report ❑ Storm water Drainage Calculations ❑ Geotechnical Report 0. Preliminary Access'Report(Sight Distance) ❑ Proposed Plat El Pathway Design(if applicable) ❑ Water Department Approval ❑ Engineers Construction Estimate PUBLIC FACILITY IMPROVEMENT PERMIT City ofTigard ° 13125 SW Hall Blvd. ° Tigard,Oregon 97223 ° www.tigard-or.gov ° 503-718-2421 ° Page 3 of4 SAMPLE SKE'T'CH: y S�r _ E e cof Ravemeni I bitch r OWrr a a arae re ■.rte Rain Doiju y I . {! °`l' i 1 �.I� � �,i � D�rte:+��, •. -- i A o. EL i -,rte I orA I i Rein 'h : P care;p coil a I s I ° i 1 I�. T,74e-rt�ICin� 1 f I I Fire� Hydrant FG-ii f � ) e � ° I Scale: 1'=30. 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 A��® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `.� 06/28/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Leslie Perry AIC Insurance Agency LLC PHo Ext): 541-504-1822 1 ac No: 541-923-4348 847 SW 6th St nDDRIesS: (perry@aicinsagency.com Redmond,OR 97756 INSURERS AFFORDING COVERAGE NAIC# INSURER A: AMTRUST International UW LTD INSURED INSURER B Pacific General Construction LLC INSURER C: PO BOX 220179 INSURER D: MIIWaukle,OR 97267 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 9 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE WVDPOLICY NUMBER MM/DD/YYYY MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY XIV 105804701 08/25/2017 08/25/2018 EACH OCCURRENCE $ 1,000 000 X l OCCUR DAMAGE R(RENTED CLAIMS-MADE PREMISES Ea occurrence) $ 1,000,000 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PEC LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident 1 $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ I $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN For Insurance Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE L ski, Perr LMP ©1988-201 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by LMP on June 28,2018 at 01:42PM Fef r,c-0 301 ,�L f-'; y Ifo �FYI