PFI2014-00060 V 0 i
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT 1,,l
■ Request Permit Action
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.govv,/
FROM: Owner [:1Applicant E-] Contractor �Q City Staff
(check one) \\
REFUND OR Name:
INVOICE TO: (Business or Individual) Gy-iar\ �el -P— _ w n )a-�Q/
N W Z r
Mailing Address: 22 \cf v
City/State/Zip: FOY4-t", D�, a-120 q
Phone No.: '503- 22(p - "I,)
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
CANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT(do, not cancel permit).
Permit#: Pf I ZnIq- c)0 o (iFD
Site Address or Parcel#: I z(o 5 5 w -7;Ln d Av1'.
Project Name:
Subdivision Name: Lot#:
EXPLANATION: 2-"'n D U'Z oyl- 'SP c t�2 a 1f- ,-1 J
a ]2r I C'a'l OKI
Signature: 2-ei -DlU1:S CCK) Date: �o`� b f
Print Name:
Refund Pubcv
1. The Community Development Director or Building Official may authorize the refund of
a) any fee which was erroneously paid or collected.
b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 809/6 of the land use application fee for issued pen-nits.
d) not more than 80%of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 801/6 of the building permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check. Please allow 3-4 weeks for processing refund requests.
Rte to Sys admin: Date By Rte to Admin: Date / / B
Refund Processed: Date / / B Invoice Processed: Date B
Permit Canceled: Date / B arcel Ta Added: Date B
Receipt# Date Method Amount$
I:\Building\Foffns\ReqPerffiitAction-062614.doc
City of Tigard
Public Facility Improvement
(PFI) Permit
General Information: FOR STAFF USE ONLY
Property Address/Location(s): 12265 SW 72nd Ave Engineerin',cl 2,QI4QO
WR # 3418345 aj� Cla9 Case.:
Fee:
Receipt No.:
*Applicant's Name: NW Natural Date:
Address:220 NW 2nd Av Application Accepted: SI l8 By: ACK
City/State:Portland OR Zi 97209
Primary Contact: Judith Randle REQUIRED SUBMITTAL
Phone:503-226-4211 X 4334 F,,A0k2-7'3-4A2g
INFORMATION
E-Mail: nwnpermits@nwnatural.co Professional Engineered Plans are required
1 for:
Contractor's Name: Same
• Street Widening
• Subdivision Infrastructure
CCB# xpiration: • Main utility line extension:
Address: 0 Scum Drain,Sanitary—Tigard
0 Water—Tigard Water Service Area
City/State: Zip: (includes Durham,King City and a
portion of unincorporated Washington
SX)F
Phone• ax:� County)
�f "Note:See Engineered Plan
Vns By: Submittal Checklist attached.
Address. 'A 11For all other work: Submit scaled sketch of the
\C'/Stat : Zip: work to be done. (see attached minimum sketch
requirements and provided sketch area).
\`P ne/� , F
tACU d: N\Ma013
1:\CUNPLN\Masters\land Use Applxanons\Public 1'aciBh�
Description of work:
Abandoned 3' of 1" (P) due to damage. '"°`°"`"'""d°`�
On 8/09/14 NWN crew called to site due to damage. The crew replaced T of 1" (P) 20' in ROW due to damage.
The main is on the 13' in ROW under earth. The damage location 72' S of SW Elmhurst St, damaged repaired 8/09/14.
Estimated value of work(within the public right-of-way): $
Is work related to a LAND-USE DECISION? YES ❑ NO
If so, please specify (MLP, SDR, SUB,etc.) case#:
Is the work related to a BUILDING PERMIT? YES❑ NO
If so, please specify(BUILDING PERMIT) case #:
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 1 of 5
Public roadway shall not be closed to traffic, at any time,without having first obtained written approval from the City
Engineer. The permit holder is responsible for provision of timely notification of traffic flow disruptions to area wide
Emergency Services(Tigard Police Dept.,Tualatin Fire&Rescue)and to Tri-Met and Tigard School District.
ROW 10-TRAF CTRL-MIN LANE WIDTH Continuing Notice
Minimum travel lane width shall be eleven(11)feet; pedestrian travel shall also be provided for.
ROW 20-TRENCH-PATCH/SAFETY/LBILITY Continuing Notice
A temporary hard-surface patch(Cold mix A.C. or Hot mix A.C. base paving) shall be placed on trenches within roadways
at the end of each day's work. No trench, on site or off site,shall be left at any time in an unsafe condition. The permit
holder is responsible for and is liable for hazards or damage resulting from the work.
ROW 21-REPAIRS REQ-INSPTR OPINION Continuing Notice
Work provided for under the permit shall include repair of existing facilities(roads,ditches, etc.)as may be necessary, in the
City Inspectors opinion,to overcome deterioration or damage which occurred in conjunction with the work authorized by the
permit. Corrective work shall be done at the permit holders expense.
ROW 06-TRAF CTRL-ADVANCE WARNING Continuing Notice
Advance warning of imminent traffic disruption shall be provided to the general motoring public by placement of an advance
notification sign at each end of the construction area 72 hours(min.)before initiation of construction work.
ROW 08-TRAF CTRL-DEVICES IN PLACE Continuing Notice
Traffic control devices, flagpersons,etc., shall be in place prior to initiation of construction work and shall be effectively
maintained.
ROW 11-TRAF CTRL-CITY CAN MODIFY Continuing Notice
The City reserves the right to add to or modify traffic control requirements as may be necessary to effectively control traffic
and to assure public safety.
ROW 13-HAZARDS-CERT OF INS Continuing Notice
Maintenance of the work area and approach roads is the responsibility of the permit holder. The work area and approach
roads shall be maintained in a clean condition, free from obstructions and hazards.A copy of the permit holders Certificate
of Insurance shall be available at the work area.
ROW 14-DEBRIS-MATERIALS Continuing Notice
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
cleanup and stoppage of work to accomplish cleanup.
ROW 16-REPAIRS-LIKE MATERIALS REQ Continuing Notice
Property disturbed by construction activity shall be seeded with a standard grass mix;shrubs, flowers, barkdust,existing
signs, pavement markings, mailboxes,etc., shall be reestablished, reinstalled or replaced,with like kind and material.
ROW 17-DRAINAGE CONTROL REQ Continuing Notice
Effective drainage control is required. Drainage shall be controlled within the work site and shall be so routed that adjacent
private property, public property and the receiving system is not adversely impacted. The City may, at any time,order
corrective action and stoppage of work to accomplish effective drainage control.
ROW 22-AS-BUILT/ENGR CERTIF REQ Continuing Notice
At the end of each year, or an a mutually agreeable yearly date, any entity making changes to its facilities in the public
right-of-way shall submit complete"as-built"drawings 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 engineers certification of installation
compliance(form attached).
ROW 07-TRAF CTRL-PRIV PROP ACCESS Continuing Notice
Access to existing properties shall be maintained at all times, including normal delivery service and mail service and if not,
shall be cause for work stoppage until effective access is established.
ROW 09-TRAF/NOISE CTRL-WORK HRS Continuing Notice
No work will be permitted during the hours of darkness, nor between 9:00 p.m. to 7:00 a.m. Monday through Friday, nor
between 9:00 p.m.to 8:00 a.m. Saturday, nor between 9.00 p.m.to 9:00 a.m. Sunday.
ROW 28-CONSTR SAFETY-RESPON PARTY Continuing Notice
The permit holder shall cause his contractor to provide to the City Inspector, in writing,the name and 24 hr emergency
telephone number of a designated"Competent Person"responsible for construction safety as per OR-OSHA, Chap.437,
Div. 3 Construction, Subdivision P-Excavations. The contractor shall notify the City Inspector of any/all assignment
changes.
a
CITY OF TIGARD v PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12014-00060
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 08/21/2014
Parcel: SEG989
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: NW Natural
Project Description: Adjacent to 12265 SW 72nd Avenue. Abandoned '3 of 1"(P)due to damage. on 8/9/14, NWN crew
called to site due to damage. THe crew replaced 3'of 1"(P)20'in ROW. The main is on the 13' in
ROW under earth. The damage location is 72'S of SW Elmhurst Street,damage repaired on 8/9/14.
SEG 989
Owner: FEES
Description Date Amount
PFI Permit Fee 08/21/2014 $300.00
PHONE.
Contractor:
PHONE:
FAX
Applicant:
JUDITH RANDLE
220 NW 2ND AVE
PORTLAND, OR 97209
PHONE: 503-226-4211
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.
PermSignature:
� prQ
Signature: 1'C 1►/,
Issued By: RDVI
Special Conditions(See Attached)
ate:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
� f f
Condit tins for PF12014-00060
Rae: Condition Name: Status: Severity:
ROW 23-DAILY INSP REPORTS REQ Continuing Notice
The permit holders Engineer/Inspector shall submit daily inspection reports,on a weekly basis,to the City's Inspector. (see
Developer-Engineer Agreement note#5).
ROW 24-TESTS/REPTS TO VALIDT CLMS Continuing Notice
The City's Inspector may,at their discretion, require provision of tests and or reports from the permit holder, permit holder's
engineer or contractor to validate claims of material or construction adequacy/compliance. Such tests/reports shall be
provided at the permit holder's expense.
ROW 25-RELEASE-WAIVER REQ Continuing Notice
The permit holder shall provide a copy of a properly executed Release&Waiver document to the City for each ownership
disturbed by construction activity, as evidence of disturbance resolution and owner satisfaction.
ROW 26-MONUMENT PROTECTION REQ Continuing Notice
Existing monuments, property corners, and survey markers shall be protected. Replacement shall be at the permit holders
expense.
ROW 29-ESMT/RT OF ENTRY-RESPON Continuing Notice
It is the sole responsibility of the permit holder to provide for 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 permit holder's failure to obtain or provide for proof of right-of-entry or easements.
ROW 12-INSP 24 HR NOTICE REQUIRED Continuing Notice
The permit holder or his contractor shall notify the City's inspector Kenny Fisher at 503-816-6146 or email at
kenny@tigard-or.gov, twenty-four(24)hours prior to commencing work,twenty-four(24)hours prior to any staged
inspection, and after completing work covered by the permit.
ROW 15-EROSION CTRL REQ Continuing Notice
Effective erosion control is required. Erosion control devices must be installed and maintained meeting D.E.Q.
requirements.The City may at any time order corrective action and stoppage of work to accomplish effective erosion
control.
ROW 18-UTILITIES PRELOCATION REQ Continuing Notice
Oregon law requires following the rules adopted by the Oregon Utility Notification Center. Said rules are set forth in OAR
952-001-0010 through OAR 952-001-0080. Copies of the rules may be obtained from the Center by calling(503)232-1987.
If you have questions about the rules, contact the Center. NOTE: Damage to utilities shall be corrected at the permit holders
expense.
ROW 19-UTILITY LOCATIONAL CONFLICT Continuing Notice
Contractor 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 permit holders expense. Changes must be approved by the City in advance of work performance. Contractor shall
coordinate the work with affected utility agencies.
ROW 27-PROB SOLVING-RESPON PARTY Continuing Notice
The permit holder shall 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 an
emergency.The permit holder shall notify the City Inspector, in writing,of any/all assignment changes.
ROW 02-PERMIT& PLAN REQ ON SITE Continuing Notice
A copy of the permit and all attachments,and a copy of the approved construction plan and all amendments shall be
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 the aforesaid must be approved by the City, in advance of work performance.
ROW 03-TRAF CTRL-SPECIF(CITY) Continuing Notice
The City's standard specification for traffic control is"Manual on Uniform Traffic Control Devices for Streets and Highways",
U.S. Dept.of Transportation, F.H.A., 1988 Ed.
ROW 04-TRAF CTRL-CONTR RESPON FOR Continuing Notice
Traffic control shall be provided for by the contractor in accordance with the City's standard specification and, also, in
accordance with a City Qob specific)approved traffic control plan.A copy of the approved traffic control plan shall be
available at the work area.
ROW 05-TRAF CTRL-ROAD CLOSURE Continuing Notice
APPLICANTS:
To consider an application complete,you will need to submit ALL of the REQUIRED SUBMITTAL ELEMENTS as described on
the front of this application in the"Required Submittal Elements"box.
NOTE: Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for work.
*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 on the
back of this form or submit a written authorization with this application
(Detailed Submittal Requirement Information sheets can be obtained,upon request,for all types of Land Use Applications)
BY SIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT:
• The above request does not violate any 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 the 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.
SIGNATURES of each owner of the subject property.
DATED this 15th day of August 20 14
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City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 2 of 5
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City of Tigard
September 18, 2014
Brian Kelly
220 NAV 2"'Ave.
Portland, OR 97209
Re: Permit No. PFI2014-00060
Dear Mr. Kelly:
The City of Tigard has canceled the above referenced permits) and encloses a refund for the
following:
Site Address: 12265 SW 72"`'Ave.
Project Name: NW Natural
Job No.: N/A
Refund Method: ® Check#214957 in the amount of$300.00.
❑ Credit card "return" receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account "deposit" receipt in the amount of$
Comment(s): Refund check was mailed separately for refund of permit fees as permit
was not required for repair of damage caused by construction work at this address.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 0 www.tigard-or.gov
City of Tigard
Accela Refund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts,documentation and the RequertfarPemiit=lotion form (if applicable) must
be attached to this request form. Refund requests are due to Accela System Administrator by
each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: Brian Felly DATE: 9/10/2014
220 NW 2"'Ave
Portland, OR 97209 REQUESTED BY: Dianna Howse
ZD
TRANSACTION INFORMATION:
Receipt#: 1973.13 Case#: PFI2014-00060
Date: 8/21/2014 Address/Parcel: 12265 S%'72"d rive
Pay Method: CreditCard Project Name: N%'Natural
EXPLANATION: Per PW/engineering request as scope of work was for repair of damage done by
contractor working at this address.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
PFI Permit Fee 100-0000-43114 $300.00
TOTAL REFUND: $300.00
APPROVALS: SIGNATI=S/DATE:
If under$5,000 Professional Staffi'�� ? 1:/UCG'"l�'._
If under$12,500 Division Manager
If under$25,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION US
Case Refund Processed: I Date:
I:\Building\Refund.-\RefundRequest.doc x 09/01/3010
CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
• COMMUNITY DEVELOPMENT Permit#: PF12014-00060
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 08/21/2014
Parcel: SEG989
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: NW Natural
Project Description: Adjacent to 12265 SW 72nd Avenue.Abandoned'3 of 1"(P)due to damage. on 8/9/14, NWN crew
called to site due to damage. THe crew replaced 3'of 1"(P)20'in ROW. The main is on the 13'in
ROW under earth. The damage location is 72'S of SW Elmhurst Street,damage repaired on 8/9/14.
SEG 989
Owner: FEES
Description Date Amount
PFI Permit Fee 08/21/2014 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
JUDITH RANDLE
220 NW 2ND AVE
PORTLAND, OR 97209
PHONE: 503-226-4211
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.
Signature:
Permittee/Applicant 1 '� r VI tp& �
Signature: knmAj
1 L ,�,�nn��Issued By: �i ou-It
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12014-00060
Type; Condition Name: Status: Severity:
ROW 23-DAILY INSP REPORTS REQ Continuing Notice
The permit holders Engineer/Inspector shall submit daily inspection reports, on a weekly basis, to the City's Inspector. (see
Developer-Engineer Agreement note#5).
ROW 24-TESTS/REPTS TO VALIDT CLMS Continuing Notice
The City's Inspector may,at their discretion, require provision of tests and or reports from the permit holder, permit holder's
engineer or contractor to validate claims of material or construction adequacy/compliance. Such tests/reports shall be
provided at the permit holder's expense.
ROW 25-RELEASE-WAIVER REQ Continuing Notice
The permit holder shall provide a copy of a properly executed Release&Waiver document to the City for each ownership
disturbed by construction activity,as evidence of disturbance resolution and owner satisfaction.
ROW 26-MONUMENT PROTECTION REQ Continuing Notice
Existing monuments, property corners,and survey markers shall be protected. Replacement shall be at the permit holders
expense.
ROW 29-ESMT/RT OF ENTRY-RESPON Continuing Notice
It is the sole responsibility of the permit holder to provide for 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 permit holder's failure to obtain or provide for proof of right-of-entry or easements.
ROW 12-INSP 24 HR NOTICE REQUIRED Continuing Notice
The permit holder or his contractor shall notify the City's inspector Kenny Fisher at 503-816-6146 or email at
kenny@tigard-or.gov,twenty-four(24)hours prior to commencing work,twenty-four(24)hours prior to any staged
inspection, and after completing work covered by the permit.
ROW 15-EROSION CTRL REQ Continuing Notice
Effective erosion control is required. Erosion control devices must be installed and maintained meeting D.E.Q.
requirements. The City may at any time order corrective action and stoppage of work to accomplish effective erosion
control.
ROW 18-UTILITIES PRELOCATION REQ Continuing Notice
Oregon law requires following the rules adopted by the Oregon Utility Notification Center. Said rules are set forth in OAR
952-001-0010 through OAR 952-001-0080. Copies of the rules may be obtained from the Center by calling(503)232-1987.
If you have questions about the rules, contact the Center. NOTE: Damage to utilities shall be corrected at the permit holders
expense.
ROW 19-UTILITY LOCATIONAL CONFLICT Continuing Notice
Contractor 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 permit holders expense. Changes must be approved by the City in advance of work performance. Contractor shall
coordinate the work with affected utility agencies.
ROW 27-PROB SOLVING-RESPON PARTY Continuing Notice
The permit holder shall 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 an
emergency. The permit holder shall notify the City Inspector, in writing, of any/all assignment changes.
ROW 02-PERMIT&PLAN REQ ON SITE Continuing Notice
A copy of the permit and all attachments, and a copy of the approved construction plan and all amendments shall be
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 the aforesaid must be approved by the City, in advance of work performance.
ROW 03-TRAF CTRL-SPECIF(CITY) Continuing Notice
The City's standard specification for traffic control is"Manual on Uniform Traffic Control Devices for Streets and Highways",
U.S. Dept. of Transportation, F.H.A., 1988 Ed.
ROW 04-TRAF CTRL-CONTR RESPON FOR Continuing Notice
Traffic control shall be provided for by the contractor in accordance with the City's standard specification and, also, in
accordance with a City(job specific)approved traffic control plan.A copy of the approved traffic control plan shall be
available at the work area.
ROW 05-TRAF CTRL-ROAD CLOSURE Continuing Notice
Public roadway shall not be closed to traffic, at any time,without having first obtained written approval from the City
Engineer. The permit holder is responsible for provision of timely notification of traffic flow disruptions to area wide
Emergency Services(Tigard Police Dept., Tualatin Fire&Rescue)and to Tri-Met and Tigard School District.
ROW 10-TRAF CTRL-MIN LANE WIDTH Continuing Notice
Minimum travel lane width shall be eleven(11)feet; pedestrian travel shall also be provided for.
ROW 20-TRENCH-PATCH/SAFETY/LBILITY Continuing Notice
A temporary hard-surface patch(Cold mix A.C. or Hot mix A.C. base paving) shall be placed on trenches within roadways
at the end of each day's work. No trench, on site or off site, shall be left at any time in an unsafe condition.The permit
holder is responsible for and is liable for hazards or damage resulting from the work.
ROW 21-REPAIRS REQ-INSPTR OPINION Continuing Notice
Work provided for under the permit shall include repair of existing facilities(roads,ditches, etc.)as may be necessary, in the
City Inspectors opinion,to overcome deterioration or damage which occurred in conjunction with the work authorized by the
permit. Corrective work shall be done at the permit holders expense.
ROW 06-TRAF CTRL-ADVANCE WARNING Continuing Notice
Advance warning of imminent traffic disruption shall be provided to the general motoring public by placement of an advance
notification sign at each end of the construction area 72 hours(min.)before initiation of construction work.
ROW 08-TRAF CTRL-DEVICES IN PLACE Continuing Notice
Traffic control devices, flagpersons,etc.,shall be in place prior to initiation of construction work and shall be effectively
maintained.
ROW 11-TRAF CTRL-CITY CAN MODIFY Continuing Notice
The City reserves the right to add to or modify traffic control requirements as may be necessary to effectively control traffic
and to assure public safety.
ROW 13-HAZARDS-CERT OF INS Continuing Notice
Maintenance of the work area and approach roads is the responsibility of the permit holder. The work area and approach
roads shall be maintained in a clean condition,free from obstructions and hazards.A copy of the permit holders Certificate
of Insurance shall be available at the work area.
ROW 14-DEBRIS-MATERIALS Continuing Notice
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
cleanup and stoppage of work to accomplish cleanup.
ROW 16-REPAIRS-LIKE MATERIALS REQ Continuing Notice
Property disturbed by construction activity shall be seeded with a standard grass mix; shrubs, flowers, barkdust,existing
signs, pavement markings, mailboxes,etc., shall be reestablished, reinstalled or replaced,with like kind and material.
ROW 17-DRAINAGE CONTROL REQ Continuing Notice
Effective drainage control is required. Drainage shall be controlled within the work site and shall be so routed that adjacent
private property, public property and the receiving system is not adversely impacted.The City may, at any time,order
corrective action and stoppage of work to accomplish effective drainage control.
ROW 22-AS-BUILT/ENGR CERTIF REQ Continuing Notice
At the end of each year, or an a mutually agreeable yearly date, any entity making changes to its facilities in the public
right-of-way shall submit complete"as-built"drawings 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 engineers certification of installation
compliance(form attached).
ROW 07-TRAF CTRL-PRIV PROP ACCESS Continuing Notice
Access to existing properties shall be maintained at all times, including normal delivery service and mail service and if not,
shall be cause for work stoppage until effective access is established.
ROW 09-TRAF/NOISE CTRL-WORK HRS Continuing Notice
No work will be permitted during the hours of darkness, nor between 9:00 p.m.to 7:00 a.m. Monday through Friday, nor
between 9:00 p.m.to 8:00 a.m. Saturday, nor between 9:00 p.m.to 9:00 a.m. Sunday.
ROW 28-CONSTR SAFETY-RESPON PARTY Continuing Notice
The permit holder shall cause his contractor to provide to the City Inspector, in writing,the name and 24 hr emergency
telephone number of a designated"Competent Person"responsible for construction safety as per OR-OSHA, Chap.437,
Div. 3 Construction, Subdivision P-Excavations.The contractor shall notify the City Inspector of any/all assignment
changes.
RECEIVED
City of Tigard AUG 18 2014
_ Public Facility Improvement pLgNN/NGop T/GgRD
(PFI) Permit NG/NEER/NG
General Information: FOR STAFF USE ONLY
Property Address/Location(s): 12265 SW 72nd Ave Engineerin
Case�o.: p., 2014 C QO
WR # 3418345 C CtS9OW
Fee: 300
Receipt No.:
*Applicant's Name:NW Natural Date:
Address:220 NW 2nd Av Application Accepted:By: /-V—
City/State:Portland OR Zip:97209
Primary Contact: Judith Randle REQUIRED SUBMITTAL
Phone:
503-226-4211 X 4334 Fax:503-273-4822 INFORMATION
E-Mail: nwnpermits@nwnatural.com Professional Engineered Plans are required
for:
• Street Widening
Contractor's Name: Same • Subdivision Infrastructure
CCB# Expiration: • Main utility line extension:
Address: 0 Storm Drain,Sanitary—Tigard
0 Water—Tigard Water Service Area
City/State: Zip: (includes Durham,King City and a
portion of unincorporated Washington
Phone: Fax: County)
"Note:See Engineered Plan
Plans By: Submittal Checklist attached.
Address: For all other work:Submit scaled sketch of the
City/State: Zip: work to be done. (see attached minimum sketch
Phone: Fax: requirements and provided sketch area).
Updated:6/24/2013
I:\CURPLN\Masters\land Use Applications\Pubbc Facthty
Description of work:
Abandoned 3' of 1" (P) due to damage. L 1-p-Ve" "`do`
On 8/09/14 NWN crew called to site due to damage. The crew replaced T of 1" (P) 20' in ROW due to damage.
The main is on the 13' in ROW under earth. The damage location 72'S of SW Elmhurst St, damaged repaired 8/09/14.
Estimated value of work(within the public right-of-way): $
Is work related to a LAND-USE DECISION? YES F—] NO ❑
If so,please specify (MLP, SDR,SUB,etc.) case#:
Is the work related to a BUILDING PERMIT? YES NO ❑
If so,please specify (BUILDING PERMIT) case #:
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 503-718-2464 1 www.tigard-or.gov I Page 1 of 5
APPLICANTS:
To consider an application complete,you will need to submit ALL of the REQUIRED SUBMITTAL ELEMENTS as described on
the front of this application in the"Required Submittal Elements"box.
NOTE: Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for work.
*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 on the
back of this form or submit a written authorization with this application
(Detailed Subrruttal Requirement Information sheets can be obtained,upon request,for all types of Land Use Applications.)
BY SIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT:
• The above request does not violate any 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 the 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.
SIGNATURES of each owner of the subject property.
15th August 14
DATED this day of ,20
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Date 2014 08 15 0909'.16-02'00'
Applicant/Authorized Agent's Signature Owner's Signature
Owner's Signature Owner's Signature
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 2 of S
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