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PFI2019-00035 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT • : ' COMMUNITY DEVELOPMENT Permit#: PF12019-00035 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 01/31/2019 T f C;.l I:ng Parcel: SEG931 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: Mohulama Driveway PFI Project Description: New driveway approach on 12215 SW 128th Owner: FEES Description Date Amount PFI Permit Fee 01/31/2019 $300.00 PHONE: Contractor: PHONE: FAX: Applicant: KILL MOHULAMA 4936 NE 19TH AVE PORTLAND, OR 97211 PHONE: 503-810-3229 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/Applicant411, Signature: (4.7Issued By: ,L/MAiS Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PFI2019-00035 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 RECEIVED City of Tigard JAN 2 9 2019 " PUBLIC WORKS —ENGINEERING O fTv .,_.r • rzcliNc Public Facility Improvement (PFI) Permit -c- ., �` - " TIGARD TYPE OF WORK DESCRIPTION OF WORK(in the right-of-way) ❑ TYPE 1-Franchise Utility Work Check one: ❑ Utilities Sidewalk/driveway approach ❑Streetimprovements performed by NWN, PGE and/or utility agency. Detailed description: / P f g TYPE 2–Sidewalk/Driveway/Sewer p't'uL�� Z,� Work performed for the purpose of: Afifrr-o' -"^` / ()4_ • Sidewalk installation or repair. • Driveway approach installation Property address/location(s): i 2--24 0e, and/or repair SECS 93 1 • Sanitary sewer lateral installation and/or main line tap � R � ❑ TYPE 3-Full scale Development Applicant: '?��L-r/'Q�bC--! f�z.r Ci 'r)Address: • /� i GP / approval which includes any of City/state: A, Zip: '?7-Z// t the following: Phone 3-* -3221 Email: - ,"nr ��e7")../ __ • Subdivisions or Partitions • Contact name: Phone: Street widening • Mainline installation for Sanitary sewer, Storm sewer, Tigard water Contractor: L/ and/or Tigard Water Service Area CCB#: f 5-7- Expiration: _ Address: SUBMIT COMPLETED APPLICATION TO: ��- �zuCity Tigard of T' City/state: Zip: Planning/Engineering Phone: Email: 13125 SW Hall Blvd. Contact name: Phone: Tigard,OR 97223 Applications for"minor work in right-of-way" only may be emailed to: Engineer: rowpermits@tigard-or.gov Address: I OR S'FAH. l'SI: ONLY City/state: Zip: r Phone: Email: Case No.: P F c 2O Ici --0 d o3 5 Contact name: Application submittal fee(.007%of Engineer's Estimate) $ Estimated value of work is required(if over$5,000):$ 15;t9 '61.0 Additional fees: $ 31,6 (within the public right-of-way) Application accepted: By: rn 6 Date: If 2-q / I q Is work related to a LAND-USE DECISION? ❑ Yes ❑ No If so,please specify (MLP,SDR, SUB,etc.) case #: Application reviewed: / g By: e e Date: i 3' I Is work related to a BUILDING PERMIT? ❑ Yes ❑ No Applicant notified: If so,please specify(BUILDING PERMIT)case#: By: C(- Date: I- SO-11 I:\ENG\PermitApplications\pfi_application Rev.10/16/2017 At�eC+R.:n:r ..:.;.. 2 _'-.r .-,,.k'-..F:.:Y :..enlr3�R3.�+sY.iY..ifi.Fk ..<.,:;..,R—.•R'vSMF:m.NxYMti:-n:...�..,-x�:Yw`&..�'c:✓y�s .].i:tis'X'.n+�•W';fc4Milp'.'a7W1.M1ls)R19fv[i:;,�ep'fj1.Z Kta'f-"k.[E. -.'h9t"A�Y..1a.R::�� Gili'lit•r'Foram'a}prBA19n_%'&�;`S?: :76[�'lA'4i1GrA'Y�.t:.'S tii.; City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 1 of4 C Y 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 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. 44P6 6. 1 gotU4 f — � .,— f I 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 i PUBLIC FACILITY IMPROVEMENT PERMIT City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 2 of DEVELOPMENT ENGINEERING FEES FOR R S t A F F t SI: ONLY Public Facility Improvement(PFI)Permit: DETAILED SUBMITTAL REQUIREMEN'T'S 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 submittal fee) Sketch (including information below) Engineer's estimate X 2%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) (4 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 ❑ Composite Utility Plan(Electrical,Phone,Gas, Storm,Sanitary,Water,Signage,Street Lights,etc) ❑ Details Note: A cash/bond assurance may be ❑ 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.) ❑ Engineer's Construction Estimate 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 Provider Approval PUBLIC FACILITY IMPROVEMENT PERMIT City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 3 of4 • . SAMPLE SKETCH: iv "Ii. $ 1 Edge of Pavement -41-- Ditch ' ""101'�treetlig ,t / ,,...t. , ' (44.1 r 'f P) . Ii.. 1 , • T ,"ITFasfd''c rr1we• ri WO I • 1 : Existing House a a t 1 Exiting 31 1 :i of 2c I i4 a, • I i i up cr4 1 {; I. \ Exing Shop I I 1 Chl I e:\ . F owerpole r I = I 1 p7r7)5 I Ic--) Fire Hydrant(FH) I • ■ Scale- 'I'=30- • I 1 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 • wwwtigard-or.gov • 503-718-2421 • Page 4 of4 Vicinity Map l a�n t! T t Beaverton Ott _ p e Tr 3 a r d City of Tigard, Oregon Tura 'a 1'1 M 12135 a 1 Q l F , ,eple, CV T. '+k if __ 0 Hart V etl and t Tigard . IP - :,..,i ; i - , t -~ ` / , leis • ,� j 1 i — r } T Date re derived from multiple sources.The City of Tigard , iiii$40: v .., ? � / R I/- f makes no warranty,repreeentetion,or guarantee ss to the content,accureeY,timeliness or completeness of any of the date provided harem.The City of Tigard shell ,gilt c,- assume no liability for any errors,omieeiona.or "" inaccuracies in the inlermation provided regardless of how caused. ,.x. 122 4S 1111111 i Scale: 0.01 Miles .. City of Tigard 13125 SW Hall Blvd "w Tigard, OR 97223 II ''`�-�,.. Map Created: (503) 639-4171 TIGARD 01/29/2019 www.tigard-or.gov