PFI2019-00048 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
•
COMMUNITY DEVELOPMENT Permit#: PF12019-00048
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 02/07/2019
TIGARDParcel: 2S103CB04100
Jurisdiction: Tigard
Site address: 12290 SW MARION ST
Subdivision: WILLAMETTE NO.2 Lot: 20
Project: Beringer Sewer Connection
Project Description: Connect existing home to sewer in Tigard ROW
Owner: FEES
Description Date Amount
PFI Permit Fee 02/04/2019 $300.00
PHONE:
Contractor:
HOLLENBACH &HURD INC
5291 NE ELAM YOUNG PARKWAY SUITE 180
HILLSBORO, OR 97124
PHONE: 503-591-5987
FAX: 503-848-6832
Applicant:
JOE HURD
5291 NE ELAM YOUNG PARKWAY SUITE 180
HILLSBORO, OR 97124
PHONE: 503-591-5987
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: See application
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PFI2019-00048
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
1 +
RECEIVED
City of Tigard
PUBLIC WORKS — ENGINEERINGIN • FEB 0 4 2019
Public Improvement (PFNIRING
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
Detailed description:
Connect SFR to public sewer and/or utility agency.
ti, TYPE 2—Sidewalk/Driveway/Sewer
Work performed for the purpose of:
• Sidewalk installation or repair.
• Driveway approach installation
Property address/location(s): 12290 SW Marion St. •
and/or repair
• Sanitary sewer lateral installation
and/or main line tap
Applicant: Hollenbach & Hurd Inc. (Joe Hurd) ❑ TYPE 3—Full scale Development
5291 NE Elam YoungPkwy. Ste 180 Work performed with Land use
Address: approval which includes any of
City/state: Hillsboro, Or. Zip: 97124 the following:
Phone: 503-591-5987 Email: handh20@juno.com • Subdivisions or Partitions
Contact name: Joe Hurd Phone: 503-936-5733 • Street widening
• Mainline installation for Sanitary
Hollenbach & Hurd Inc. sewer, Storm sewer, Tigard water
Contractor: and/or Tigard Water Service Area
CCB#: 121807 Expiration: 94/15/2020
Address: 5291 NE Elam Young Pkwy Ste 180 SUBMIT COMPLETED APPLICATION TO:
City/state: Hillsboro, Or. Zip: 97124 City of Tigard
Phone: 503-591-5987 Email: handh20@juno.com Planning/Engineering
13125 SW Hall Blvd.
Contact name: Joe Hurd Phone: 503-936-5733 Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: N/A only may be emailed to:
rowpermits(ai)tigard-or.gov
Address:
FOR STAFF I.SE ONLY
City/state: Zip:
Phone: Email: Case No.: PP 0 l 9 Off'"lie
Contact name: Application submittal fee(.07%of
eo
�
Engineer's Estimate) $ O 0—
Estimated value of work is required(if over$5,000):$ Additional fees: $
(within the public right-of-way) Application// accepted: 291i
By: /�-C Date: '-2 9
Is work related to a LAND-USE DECISION? ❑ Yes ® No
If so,please specify (MLP, SDR,SUB,etc.) case #: Applicai• wed:
By: w,0/ Date: 217/1f
Is work related to a BUILDING PERMIT? ❑ Yes ® No ApplicantJ notped:
If so,please specify(BUILDING PERMIT)case#: By: h/ Date: n
b-hc)
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 denying the application.
u4 ::: Joe Hurd
App • ant/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
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CITY OF TIGARD RECEIPT
S • 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Beringer Sewer Connection
Site Address: 12290 SW MARION ST
Receipt Number: 421375 - 02/04/2019
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PMD
PF12019-00048 PFI Permit Fee 640-0000-43114 $300.00
Total: $300.00
PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 10939 LSMITH 02/04/2019 $300.00
Payor: HOLLENBACH & HURD, INC.
Total Payments: $300.00
Balance Due: $0.00
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