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PFI2019-00052 n CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT 1111 ' COMMUNITY DEVELOPMENT Permit#: PF12019-00052 T[G ARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 02/14/2019 Parcel: 2S111 BA02600 Jurisdiction: Tigard Site address: 14025 SW 98TH AVE Subdivision: MCDONALD ACRES Lot: 1 Project: Sidewalk Repair Project Description: Replace broken pipe under sidewalk and replace panel. Owner: FEES Description Date Amount PHONE: Contractor: PHONE: FAX: Applicant: PERCY TRAILL 14025 SW 98TH AVE TIGARD, OR 97224 PHONE: 503-515-4007 Total $0.00 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: ` APPLIA-J I" Issued By: (JZV: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PFI2019-00052 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 FEB 1 1 2019 1CITY'1 PUBLIC WORKS —ENGINEERING OF TIGARD • NGINEERI G Public Facile Im rovement (1tTflernitt TIGARD TYPE OF WORK DESCRIPTION OF WORK(in the right-of-way) ❑ TYPE 1-Franchise Utility Work Check one: LI Utilities 0 Sidewalk/driveway approach ❑Streetimprovements performed by NWN, PGE p P eF'\ G� �r e,ii-C L 7 p, and/or utility agency. Detailed description: e- • .'(,c1 0\ l G- 3 1 cAe-v,/ -N'( k TYPE 2-Sidewalk/Driveway/Sewer Work performed for the purpose of: • Sidewalk installation or repair. Z� LJ • Driveway approach installation Property address/location(s): 1 Li-O and/or repair 5 / MI z O. ‘ 1 2-2-/-- • Sanitary sewer lateral installation and/or main line tap F----e-6.--y �-- �� ❑ TYPE 3-Full scale Development Applicant: Work performed with Land use Address: i1/4+O 25 4" e10 AVE- approval which includes any of City/state: TiG>-� 4:92 Zip: -7-7-29_ the following: / Phone:�d 3_ t� Lico7Email: PeY ) 14 4'1'6'11 I( . I-z ri, I (�� ' Subdivisions or Partitions � • Street widening Contact name: Fere I'{'&�i I) Phone: (5,0_3) IS Lf-co4 • • Mainline installation for Sanitary Contractor: sewer, Storm sewer, Tigard water and/or Tigard Water Service Area CCB#: Expiration: Address: SUBMIT COMPLETED APPLICATION TO: City/state: Zip: City of Tigard Phuming/Engineering Phone: Email: 13125 SW Hall Blvd. Contact name: Phone: Tigard,OR 97223 Applications for"minor work in right-of-way" Engineer: only may be emailed to: rowpermits®tigard-or.gov Address: FOR S`I'AI I. l SE ONL\ City/state: Zip: Phone: Email: Case No.: .17-Ft c2O1'9‘ -0 60' Contact name: Application submittal fee(.007%of Engineer's Estimate) $ Estimated value of work is required(if over$5,000):$ Additional fees: $ ...-413' (within the public right-of-way) Application accepted: By: Date: /i1/' Is work related to a LAND-USE DECISION. ❑ Yes ❑ No If so,please specify (MLP,SDR,SUB,etc.) case #: Application reviewed: By: 83 Date: a-////7 Is work related to a BUILDING PERMIT? ❑ Yes ❑ No Applicant notified: If so,please specify(BUILDING PERMIT)case#: By: 5 L- Date: Z-14 1 I:\ENG\PermitApplications\pfi_application Rev.10/16/2017 City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • 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 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. li,..,-..._ - __.--- ,., da _ _ ' ir-c-j-, 1 RAAL-L_ VI \/ ot Ap eli 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 ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 2 of4 DEVELOPMENT ENGINEERING FEES FOR R SIAFf' t SE ONLY Public Facility Improvement(PFI)Permit: DETAILED SUBMITTAL APPLICATION FEE REQUIREMENTS 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: 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 • wwwtigard-or.gov • 503-718-2421 • Page 3 of4 , SAMPLE SKETCH: (c) .5.01_ •• „si_ •• 5..i.,, i Edge of P avernent Q. i 1*-1e1116‘ -4u— Duch —go. Sireellit�r -_•—•-•-----•—•—r--- r • L � A�, 4 • i�*i11 • i' ' 1 • T!'Pr o'p osTd'an rine'_' 1 a, • > tallih. I Existing House 1 I u: I Exrsting I ,,e • Driveway 0-I .p.),‹ 1 �.1 4II 11 • vi ,rfe 1 4 I I. I Existing Shop 1 ipowerpole • I = I o . o ' r !a- 95' I --- -•--Tlio-pW 8•w• •�•Z�•w• I• I j IN, IY • Fire Hydrant(FH) I I ,, • I, ! Scale- .t..=30- I ! •I I III 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 N\6D00, \ rAkfttlevil 1407_5e4cek Afc -