PFI2019-00275 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
lig COMMUNITY DEVELOPMENT Permit#: PF12019-00275
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 08/27/2019
T f c;,tti.L] g Parcel: 2S103BB10400
Jurisdiction: Tigard
Site address: 12180 SW KATHERINE ST
Subdivision: YE-OLDE WINDMILL Lot: 24
Project: Siu Sewer
Project Description: Replace sewer from transition in roadway.
Class of Work: FEES
Type 2-Sidewalk/Driveway Approach Description Date Amount
PFI Permit Fee 08/27/2019 $300.00
Owner: Total $300.00
REQUIRED INSPECTIONS
Call 503-639-4175 for the IVR inspection request line or visit the City of
PHONE: Tigard website at www.tigard-or.qov to schedule inspections online.
Contractor:
3 MOUNTAINS PLUMBING
524 N TILLAMOOK ST
PORTLAND, OR 97227
PHONE: 5036701342
Applicant:
ANDREA AMAYA
524 N TILLAMOOK ST
PORTLAND, OR 97227
PHONE: 5036701342
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 Tv
Signature: S
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PFI2019-00275
Type: Condition Name: Status: Severity:
PFI_Sidewalk/[ 19-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/[ 20-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/[ 21 -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/[ 22-DAILY INSPECTION REPORTS Applied Notice
Applicant shall submit daily inspection reports, on a weekly basis, to the City's Inspector.
PFI_Sidewalk/[ 23-MONUMENT PROTECTION Applied Notice
Existing monuments, property corners, and survey markers shall be protected. Replacement shall be at the permit holder's
expense.
PFI_Sidewalk/[ 24-VALIDATION OF MATERIAL/CONSTRUCTION Applied Notice
The City's Inspector may, at his discretion, require tests and or reports from the applicant to validate claims of material or
construction adequacy/compliance. Such tests/reports shall be provided at the applicant's expense.
PFI_Sidewalk/[ 25-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/[ 26-RIGHT OF ENTRY/EASEMENTS Applied Notice
Applicant to obtain proper right-of-entry and/or easements prior to starting work. Proof of right-of-entry or properly executed
easements, shall be provided to the City. The City shall in no way be construed to be liable for the applicant's failure to
obtain or provide for proof of right-of-entry or easements.
PFI_Sidewalk/[ 27-PRIVATE PROPERTY AGREEMENTS Applied Notice
Provide the City a copy of an executed agreement[s]from the owner for each private property disturbed by construction
activity.
PFI_Sidewalk/[ 28-AS-BUILT DRAWING Applied Notice
One as-built drawing showing all new public improvements, including any revision made to the previously approved
construction plans and, also, any improvement which may impact an existing public system or facility, shall be provided to
the City by a registered civil engineer along with an engineer's certification of installation compliance(Certificate of
Compliance).
PFI_Sidewalk/[ 31 -OTHER Applied Notice
Other
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-TRAFFIC CONTROL SPECIFICATIONS Applied Notice
Applicant shall provide traffic control according to the current edition of the"Manual on Uniform Traffic Control Devices
[MUTCD]for Streets and Highways", U.S. Dept. of Transportation, FHWA, current edition,American Traffic Safety Services
Association[ATSSA], and Oregon Temporary Traffic Control Handbook[OTTCH].
PFI_Sidewalk/[ 06-TRAFFIC CONTROL PLAN Applied Notice
Submit a job specific traffic control plan. A copy of the approved traffic control plan shall be readily available at the work
area. Traffic control devices, flag persons, etc.,shall be in place prior to initiation of construction work and shall be
effectively maintained.
PFI_Sidewalk/[ 07-TRAFFIC CONTROL ROAD CLOSURE Applied Notice
Public roadway shall not be closed to traffic, at any time,without obtaining written approval from the City Engineer. The
applicant is responsible to provide 48 hour advance notice of traffic flow disruptions to affected businesses, residents and
area wide Emergency Services:503-629-0111 (Tigard Police Dept., Tualatin Fire&Rescue)and to 503-962-8140(Tri-Met)
and 503-431-2345(Tigard School District)and other service providers impacted by such closure.
PFI_Sidewalk/[ 08-TRAFFIC CONTROL ADVANCE WARNING Applied Notice
Advance warning of traffic disruption shall be provided to the public by placement of an approved advance notification sign
at each end of the construction area 72 hours(min.)before initiation of construction work.
PFI_Sidewalk/[ 09-TRAFFIC CONTROL PROPERTY ACCESS Applied Notice
Access to existing properties shall be maintained at all times, including normal delivery service and mail service. Obtain City
approval of any access closures.
PFI_Sidewalk/[ 10-TRAFFIC CONTROL WORK HOURS Applied Notice
Work is permitted in daylight between the hours of 7:00 a.m.to 7:00 p.m. Mon-Fri unless otherwise authorized by the City.
PFI_Sidewalk/[ 11 -TRAFFIC CONTROL LIMITED WORK HOURS Applied Notice
Hours of construction work on collector and arterial roads will be limited to 9:00 a.m.to 3:00 p.m. unless authorized by the
City Engineer. Work will not be permitted on collector and arterial roads between 3:00 p.m. to 9:00 a.m. unless authorized
by the City Engineer.
PFI_Sidewalk/[ 12-TRAFFIC CONTROL MODIFICATION Applied Notice
The City reserves the right to add to or modify traffic control requirements as necessary to effectively control traffic and to
assure public safety.
PFI_Sidewalk/[ 13-DRAINAGE CONTROL Applied Notice
Drainage shall be controlled within the work site and shall not adversely affect adjacent private property, public property and
the receiving system. The City may at any time order corrective action and suspension of work to accomplish effective
drainage control.
PFI_Sidewalk/[ 14-UTILITY NOTIFICATION Applied Notice
Oregon law requires following the rules adopted by the Oregon Utility Notification Center. Said rules are set forth in OAR
952-001-0100 through OAR 952-001-0080. Copies of said rules may be obtained from the Center by calling 503-246-1987.
If you have any question about the rules, contact the Center. NOTE: Damage to utilities shall be corrected at the permit
holder's expense
PFI_Sidewalk/[ 15-UTILITY LOCATION CONFLICT Applied Notice
Applicant must verify all existing utilities for both vertical elevation and horizontal location prior to start of work(pothole
before digging if necessary). Should conflicts arise and redesign or relocation of facilities be necessary, it shall be done at
the applicant's expense. Changes must be approved by the City in advance of work.Applicant shall coordinate the work
with affected utility agencies.
PFI_Sidewalk/[ 16-TEMPORARY PATCH Applied Notice
A temporary hard-surface patch shall be placed on trenches within roadways at the end of each work shift. Obtain advance
approval of patching method. No trench shall be left at any time in an un-safe condition. Applicant is responsible for and is
liable for hazards or damage resulting from the prosecution of the work.
PFI_Sidewalk/[ 17-REPAIR OF EXISTING FACILITIES Applied Notice
Work under this permit shall include repair of existing facilities(roads,ditches,etc.)as may be necessary, as determined by
the Inspector,to overcome deterioration or damage which occurred in conjunction with the work authorized by the permit.
Corrective work shall be done at the applicant's expense.
PFI_Sidewalk/[ 18-SEWER SYSTEM TEST Applied Notice
A sewer system air-test and/or DVD T.V.test report and one set of"As-Builts"shall be provided for review and approval.
RECEIVED
AUG 2 6 2019
IIIIIa City of Tigard CITY OF TIGARD PFI#:2.01q- 0021C
i ENGINEERING DI PARTMEI ANNING/ENGINEF_RING
l i i A R 1) Public Facilities Improvement (PFI) Permit
PROJECT INFORMATIONA ` (\` TYPE OF WORK
VV (
Project name: V�\ \, ) \v L TYPE 1—Franchise Utility Work
J vz `(1 C` . C'.60,./Oe.c performed by NWN,PGE, or utility
Brief description� / of project: v.l� a ene�
Y aA% O(\ akU \ CAI I TYPE 2—ROW Sidewalk/Driveway/Sewer
`�1
1 Work performed for the purpose o£
�`'f��
• Sidewalk installation or repair
• Driveway approach installation and repair
SITE INFORMATION t t p �,,n • Sanitary sewer lateral installation and
Location (address if available): `1` b0 sus l��l 1C,Y'1 main line tap
17 TYPE 3—Full Scale Development Work
s\- `, Diard t c"z t t 1 27_3 performed with land use approval which
includes any of the following:
• • Subdivisions or Partitions
APPLICANT INFORMATION • Streetwidening
Name: `,�• 7\r p a-v L`,_C • Mainline installation for sanitary sewer,
,,
‘... storm sewer, Tigard water, and Tigard
Mailing address: �` �\ 1l� ikve water service area
f�r,a t Oca Zip: °c:-•i Z,r' 17 TYPE 4—Small Cell Technology
City/State: ` l.A � 1
r O _,�A-� l: TYPE 5—Tigard Triangle
Phone: n�Cj
Email:ckvseciKS .3 orourestkrG Phone: ! NOTE: Type 1 and 2 applications may be
9\V1(V1\O\'n0)• C...OW\ emailed to row permitstbtigtrd-or.gov.
Contact name: �Yl r re4 tAYv\rj C.
Phone: DC:S3 ` cep 10 - \342 Email:
CONTRACTOR INFORMATION (Same as applicant rr��
Name: �kreb\St.. SeOar\ WC1"t-'",CCB Number: \CO" C\
Mailing address: CA ►J aNAb\YlG t s3 City/State: 91N-V\C`C0\ t dA2-- 'Lip: a-12 V1--
Phone: le1/4)"- - (61 0 - 1 2 2- Email: Yer'mR -9)i-AUU"k \n`j VAU'Mlo t rye •(Gl'►'1
ENGINEER INFORMATION
Name: !V IP\
Mailing address: City/State: Zip:
Phone: Email:
ADDITIONAL INFORMATION `
Estimated value of work is required(if over$5,000):$ \2 00 (within the public right-of-way)
Is work related to a LAND USE DECISION? 0 Yes No Case number: N I t \
City of Tigard • 13125 SW I lall Blvd. • Tigard,Oregon 97223 • www:tigard-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 15.04.140.
With the exception of a utility operating pursuant to a valid franchise or license with the City of Tigard,when the owner and the applicant
arc 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 must sign this application in the space provided or submit a written authorization with this
application. Franchised or Licensed Utilities are not required to obtain the owner's signature on the application.
I,the applicant,certify that:
• To the best of my knowledge,all the information provided within this application package is complete and
accurate.
• 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,I will exercise the rights granted in accordance with the terms and subject to all the
conditions and limitations of the approval.
''Aid%G CNAY1CA vkG 8/23119
Applicant's or ;,,+:rized agent's signature Print name Date
Property owner's signature (if required) Print name Date
t'SL_ C)\I.\
Case No: W12016-00 2.15 Permit fee: 1-6410-Go Received by: i Date:C—2( Lc\
Approved by: Tn.S t3 Date: $/Z L//1 Notified by: FtL Date: % vi
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 2 of 4
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