PFI2019-00012 liN CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PFI2019-00012
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 01/16/2019
T[[�.1 R Dg Parcel: SEG1686
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Ness Campbell Crane and Rigging
Project Description: Proposal for temporary crane activity to remove a hot tub at 13764 SW Mistletoe Dr
Owner: FEES
Description Date Amount
PFI Permit Fee 01/11/2019 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
LEE BROWN
5730 NE 138TH AVE
PORTLAND, OR 97230
PHONE: 971-221-4663
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: ---7
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PFI2019-00012
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/[ 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.
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/[ 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
, f
City of Tigard
-IN '': PUBLIC WORKS — ENGINEERING ,JAN 0 9 201B
Public FacilityImprovemeat;*0t
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
I TYPE 1-Franchise Utility Work
Check one: ❑ Utilities ❑ Sidewalk/driveway approach ZI Streetimprovements performed by NWN, PGE
and/or utility agency.
Detailed description: Temporary crane activity for removal of
hot tub from backyard of residence. ❑ TYPE 2-Sidewalk/Driveway/Sewer
Work performed for the purpose of:
• Sidewalk installation or repair.
• Driveway approach installation
Property address/location(s): 1374 SW Mistletoe Dr. and/or repair
Tigard, OR 97224 &•5 /eeg(sa • Sanitary sewer lateral installation
and/or main line tap
Applicant: NessCampbell Crane + Rigging El TYPE 3-Full scale Development
ppWork performed with Land use
Address: 5730 NE 138th approval which includes any of
City/state: Portland, OR Zip:97230 the following:
Phone:800-932-6766 Email:l.brown@nesscampbell.com • Subdivisions or Partitions
• Street widening
Contact name: Lee Brown Phone: 971-221-4663
• Mainline installation for Sanitary
sewer, Storm sewer, Tigard water
Contractor: N/A - and/or Tigard Water Service Area
CCB#: Expiration:
Address: SUBMIT COMPLETED APPLICATION TO:
City/state: Zip: City of Tigard
Phone: 1':mail: Planning/Engineering
13125 SW Hall Blvd.
Contact name: Phone: Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: N/A only may be emailed to:
rowpennits a tigard-or.gov
Address:
FOR STAFF USE ONLY
City/state: Zip:
Phone: Email: Case No.:PP/•20/9— C9°6/bZ_
Contact name: Application submittal fee(.07%of
Engineer's Estimate)
oma•
Estimated value of work is required(if over$5,000):$< $5000.00 Additional fees: $ 300 �-
(within the public right-of-way) Applicatik.2
n accepted:
B��: Date: 19h
ci
j ? y� l
Is work related to a LAND-USE DECISION. ❑ Yes � No
If so,please specify (MLP,SDR,SUB,etc.) case#: Application reviewed:
B : 2519 Date: f//op
7y�
Is work related to a BUILDING PERMIT? ❑ Yes ;SI No Applicant notified:
If so,please specify(Bi'•.,...-C
UILDING PERMIT)case#: By: Date: 1//DA 9
I:1ENG\PermitApplicadons 1pfi_a pplication Effective 10/16/2017
Cit-v of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 1 of 4
I r
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.
\X/ith 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 he 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 APPLICANT(S) SHALL CERTIFY THAT:
• 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.
Lee Brown 1/9/2019
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 of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 2 of 4
DEVELOPMENT ENGINEERING FEES FOR STAFF USE ONLY
Public Facility Improvement(PFI)Permit: DETAILED SUBMITTAL
APPLICATION FEE REQUIREMENTS
Part 1: Required submittal fee$300.00
FRANCHISE UTILITY AND SIDEWALK/
PERMIT FEE DRIVEWAY AND UTILITY
CONNECTIONS,ETC.
Part 2: Ali non-water system improvements (work in the right of way)
Engineer's estimate X 5%(less$300.00 submittal fee)
Engineer's estimate X 2%Plan Review Sketch
(including information below)
WATER SYSTEM FEE
❑ Dimensions
Part 3: All public water system improvements ❑ Street Name
Engineer's estimate X 12% ❑ Site Address
PFI Permit Fee Exemptions: FULL SCALE DEVELOPMENT
There will be no permit fee charged,or assurance required
for the following types of work: (Subdivisions/Partitions and Street Improvements)
• Sidewalk repair(less than 20 lineal feet)
• Relocate or replace mailbox Design Plans
• Ditch cleaning that does not involve regrading. (6 sets,24x36 or 22x34)
• Weep hole repair ❑ Cover—Site,Vicinity,Abbreviation,Legend
• Curb repair or replacement(less than 20 lineal feet) ❑ General Notes(City,Water,Sewer,etc.)
• Lawn sprinlder 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
• Test wells ❑ Grading
❑ Landscaping/Tree Plan
❑ Composite Utility Plan(Electrical,Phone,Gas,
Note: A cash assurance may be required per Storm,Sanitary,Water,Signage,Street Lights,etc)
TMC 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 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 of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 3 of 4
I •
SAMPLE SKETCH:
9 \\
_ ,• ,• I
Edge of Pavement
,*--- Ditch -W-
I\Streetlight
•—•---.—•—.---•—r---
1i
ain
t:, – b
1 t 4
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■
T—P oj'os'ir�
fcev7 in7—
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I i7,• I Existing House
I .. til 1 Existing
< :1 . Driveway 1
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ill-I
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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 SAX'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 • www.tigard-or.gov • 503-718-2421 • Page 4 of 4
1 2 3 4 I 5 6 7 8 9 10
SW MISTLETOE DR 2 EA SIDEWALK CLOSED TYPE 3
4 EA ROAD CLOSED TYPE 3
A
CLOSURE 3 EA ROAD CLOSED AHEAD
A
B B
ROAD
CLOSED
AHEAD
C C
•
D D
r�7
SIDEWALK
CLOSED
ROAD
CLOSED
AHEAD
E E
ROAD
MO
CLOSED III
romr
F F
ROAD
CLOSED
DATE. TIME: AHEAD
CONTACT:
LEE BROWN
NESS CAMPBELL CRANE
G L.BROWN@NESSCAMPBELL.COM Ni$1111G
971.221.4663
SHEET. NESS CAMPBELL
1 OF 1 CRANE + RIGGING NOT TO SCALE; ADJUST TO FIELD CONDITIONS
1 i 2 i 3 i 4 5 i 6 1 7 1 8 9 i 10