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PFI2019-00044 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT ,114 COMMUNITY DEVELOPMENT Permit#: PF12019-00044 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 02/07/2019 T I C;A l�T_� g Parcel: 2S114BD03400 Jurisdiction: Tigard Site address: 9500 SW RIVERWOOD LN Subdivision: COPPER CREEK STAGE 3 Lot: 74 Project: Boehm Sewer Repair Project Description: Adjacent to 9500 SW Riverwood Lane. Sanitary sewer repair via trenching in street 12 feet. Owner: FEES Description Date Amount PFI Permit Fee 02/04/2019 $300.00 PHONE: Contractor: ALPHA ENVIRONMENTAL SERVICES INC 11080 SW ALLEN BLVD, SUITE 100 BEAVERTON, OR 97005 PHONE: 503-292-5346 FAX: Applicant: JOCELYN JOHNSON 11080 SW ALLEN BLVD, SUITE 100 BEAVERTON, OR 97005 PHONE: 503-292-5346 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 h Signature: A{� u� .6*J Ct,c)L Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PFI2019-00044 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 City of Tigard RECEIVED �� PUBLIC WORKS — ENGINEERING FEB 2019 ARD Public FacilityImprovement PFI 1IIt CVEERINC TYPE OF WORK DESCRIPTION OF WORK(in the right-of-way) �� ❑ TYPE 1—Franchise Utility Work Check one: L� Utilities ❑ Sidewalk/driveway approach ❑ Streetimprovements performed by NWN, PGE and/or utility agency. Detailed description: &kn., TYPE2—Sidewalk/Driveway/Sewer - .ri , .c. i r Vic +-ienc I) 1 L i Work performed for the purpose of: i n _ r,,, t • Sidewalk installation or repair. • Driveway approach installation Property address/location(s): 0 _�5'eit. � .i�tt and/or repair ( i c C't rid 1 e)/c2- q 7 • Sanitary sewer lateral installation and/or main line tap ❑ TYPE 3—Full scale Development Applicant: Work performed with Land use Address: approval which includes any of City/state: Zip: the following: Phone: olttP EmailS: • Subdivisions or Partitions • Street widening Contact name: Phone: ff 1 • Mainline installation for Sanitary Contractor: A l9rAh... rir\v t Y-Cn m e_h-frAl 4e"r vice_S sewer, Storm sewer, Tigard water and/or Tigard Water Service Area CCB#: 1,��' '-) v-5- Expiration: Address: 1,10&0 SIA Ki L L e i1 131 vd , SI-e , fn SUBMIT COMPLETED APPLICATION TO: City/state: BCiLi4?xIDfl Zip: 01 )OC)..c- City of Tigard Phone: - 1323-7/I/Email: s r . L14— Planning/Engineering • ��`- A `i�� ' a. 13125 SW Hall Blvd. Contact name: �.)C ce cJ \ y, Phone: 911-713-/& ) Tigard,OR 97223 Applications for"minor work in right-of-way" Engineer: only maybe emailed to: rowpermits(aitigard-or.gov Address: FOR STAFF USE ONLY City/state: Zip: Phone: Email: Case No.:PF 2 1''1 `O LI Contact name: Application submittal fee(.07%of Engineer's Estimate) $ .��-� "' poi Estimated value of work is required(if over$5,000):$ � Additional fees: $ (within the public right-of-way) Application accepted: ii ,,• By: Date: ! Li tq Is work related to a LAND-USE DECISION? ❑ Yes R No If so, please specify (MLP, SDR, SUB, etc.) case#: Application .�,,/ By: Date: 41," Is work related to a BUILDING PERMIT? ❑ Yes No Applicant notified: If so,please specify(BUILDING PERMIT)case#: By: . L Date: I:\ENG\PermitApplications\pfi_application Effective 10/16/2017 City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 1 of 4 , 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 d' nying the application. 4 If Iri ( i'1 1 --ig , 'Plic ! orize'. •ent'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: All 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% LI 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 sprinkler system installation or repair ❑ Street(Plan,Profile) • Street tree pruning or planting El 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) 111 Details ❑ Traffic Sight Distance ❑ Signing and Striping El 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) El Traffic Report ❑ Storm water Drainage Calculations ❑ Geotechnical Report ❑ Preliminary Access Report(Sight Distance) ❑ Proposed Plat ❑ Pathway Design(if applicable) El Water Department Approval El Engineer's Construction Estimate PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 3 of 4 } Vicinity Map ra BeavertonIC _MapTitle Tigard City of Tigard, Oregon - NOit Tax Lots Tualatin ` e'er ,yam _ 111 r 96,Imo rll ''- ''' ' w • a r. Iii • ----.v: - „ . " , 7" .,...„. ..- ,, ,Agt *>` 1H, -. - i:. - • al �� Data:a derived Irom multiple sources.The City of Tigard o,lam makes no r^'cc urt y.repre sa ntelion,or gueranlee es to _� the conte of acv timalinesa o completeness of any e.ti of tha data provided here rn.The'C tty of Tigard shall q o lie bil rtv for any a Bions.o qy, - :nac cura c:es in the int orm atron pr orvrdad'regerdless of �f _- how caused. 1 a = y 44,to a -- .A.w... '' Scale: 0.01 Miles City of Tigard xi 13125 SW Hall Blvd e Tigard, OR 97223 411114 111116""F Map Created: (503) 639-4171 TIGARD 02/04/2019 www.tigard-or.gov