PFI2014-00098 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
a COMMUNITY DEVELOPMENT Permit#: PF12014-00098
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 11/17/2014
Parcel: 2S 103AC01800
Jurisdiction: Tigard
Site address: 11200 SW FONNER ST
Subdivision: WALNUT GLEN Lot: D
Project: Booth
Project Description: Connect existing house to sewer.
Owner: FEES
Description Date Amount
PFI Permit Fee 10/28/2014 $300.00
PHONE PFI Permit Fee 11/17/2014 $85.00
Customer Deposit 11/17/2014 $5,500.00
Contractor:
PHONE.
FAX:
Applicant:
DAVID BOOTH
3005 N PACIFIC HWY.
RICKREALL, OR 97371
PHONE 503-332-3077
Total $5,885.00
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:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12014-00098
Tv pe: Condition Name: Status: Severity:
PFI_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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 8 Rescue)and to 503-962-8140(Tri-Met)
and 503-431-2345(Tigard School District)and other service providers impacted by such closure.
PFI_Utilities 08-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_Utilities 09-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_Utilities 10-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_Utilities 11 -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_Utilities 12-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_Utilities 13-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_Utilities 14-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_Utilities 15-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_Utilities 16-PRECONSTRUCTION MEETING Applied Notice
Before initiating any construction activity,the applicant shall coordinate with the City's inspector, <Ray Woolf>at
<503-969-4507>,to establish a preconstruction meeting.
PFI_Utilities 17-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_Utilities 18-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_Utilities 19-MONUMENT PROTECTION Applied Notice
Existing monuments,property corners, and survey markers shall be protected. Replacement shall be at the permit holder's
expense.
PFI_Utilities 20-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 Utilities 21 -OTHER Applied Notice
S
7
City of Tigard
s PUBLIC WORKS— ENGINEERING
Public Facility Improvement (PFI) Permit
DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL
Check one:9 Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS
'
Detailed description: a pyk Minor work in right-of-way
�t
(sidewalk repair,curb cut,street
S L W rr 1 opening,etc.)requires:
•Application form,completed
and signed
_ (' •Submit one(1)copy of scaled sketch
Property address/location(s): I Z Y VJ 0""Y b of the proposed work to be done
q Q- J 0 ,., •Submit one(l)copy of traffic
l control plan
—OR—
n ❑ Substantial project work requires
Applicants name: ll �fl rr,, above items and professional
Address: 300 -
d.0 .Lk engineered plans for-
-
or•Street widening
City/state: V-eZip: _ R 3 •Subdivision infrastructure
Phone: mail: ,,, s Lt , Vl t 1 •Main utility line extension:
- Storm Drain,Sanitary—Tigard
� ,, p� �� ` f `y. - Water—Tigard Water Service
Contractors name: ," e r , 1t��L�— �CIVrUOVI&-_oL'tki"J 1^ Area(includes Durham,King City
CCB#: I Jq1 ZSExpiration: 4c— and a portion of unincorporated
Address:
0 S W Washington County)
�: 1}ZZ DELIVER APPLICATION TO:
IF City/state: Zip:
City of Tigard
PhonL52 3 2�Email: Planning/Engineering
/ 13125 SW Hall Blvd.
Engineer's name: Tigard,OR 97223
Applications for"minor work in right-of-way"
Address: oah•may be emailed to:
City/state: Zip: mmWanitskitigard-or gm
Phone: Email:
� a-a
Estimated value of work (within the public right-of-way): $ '60M Case No.:
Application submittal fee:
366
Is work related to a LAND-USE DECISION? ❑ Yes XNo Application accepted:
If so, please specify (MLP,SDR,SUB,etc.) case #: By: 8-f2 Date: 1 U/Zg' 1q
Is work related to a BUILDING PERMIT? A Yes ❑ No Appli on reviewed:
If so,please specify(BUILDING PERMIT)case#: By. W' Date. II y
Applicant notified:
By: Date: if/
1.\cuaruWVAaMaW"e use AWk&U : aer:07/16/014
City of Tigard • 13125 SW Hall 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.
*When the owner and the applicsutt are different people,the applicant must be the purchaser of accord 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.
BY SIGNING BELOW,THE APPLICANTS) SHALL CERTIFY THAT.
• The above reQuest does not violate any deed restrictions that may be attached to or imposed tenon the subject proper
• 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 c2ch owner of the subject property required.
Applicant/Authorized Agent's signature Print name Date
Owner's signature Print name Date
Owners signature Print name Date
Owners signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-ongov 503-718-2421 • Puge 2 of 4
a
DEVELOPMENT ENGINEERING FEES
1. Public Facility Improvement(PFI)Permit:
Part 1: Required submittal fee$300.00
Part 2: All non-water system improvements
Engineer's estimate X 5% (less$300.00 submittal fee)
Engineer's estimate X 210 Plan Review
Part 3: All public water system improvements
Engineer's estimate X 12%
Total Permit Fee =Part 2+ Part 3
PFI Permit Fee Exemptions:
There will be no permit fee charged,or assurance required for the following types of work:
• Sidewalk or driveway repair(less than 20 lineal feet)
• Relocate or replace mailbox
• Ditch cleaning that does not involve regrading.
• Weephole repair
• Curb repair or replacement(less than 20 lineal feet)
• Lawn sprinkler system installation or repair
• Street tree pruning or planting
• Planter strip landscape maintenance
• Test wells
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2421 Page 3 of 4
A
SAMPLE SKETCH:
I
I Edge orpavesneml
Ditch
Streetlight -I — -------------C---
I • ° PAit Draa1
1 I t de .. 0-11, " P .]
o
t
1 0
' T-7ropmew e–
Existing House
I I rr ( Existing
,. N Driveway
7511 I
C 1 F I � �•
1 I I rl
3 I •
o�
>
NI V 1 I 1
OSI .
Existing Shop �
� J
Powerpole
Ia 951
-------FiopertyLne----------
� I
1
I I Fire Hydrant(FH)
� � I
Scale: 'I
� I I
� I I
� I I
� � 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 of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 4 of 4
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SCALE: // ` I APPROVED BY: DRAWN BY
DATE: ' 1O-v7j�>--1 REVISED
S f I loo S%^/ t-o N N EE S*
DRAWING NUMBER
T Cf4RD 7 2.23
TCity of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
zipi Request for Permit Action
13125 SW Hall Blvd. •Tigard,Oregon 97223 . 503-718-2439 • www.ti��ard-or.gov
d-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) 80
62
Mailing Address: /
City/State/Zip: kllkrealll
Phone No.: So.3-33a— 3D71-7
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED4 "�14 (✓):
VOID PERMIT APPLICATION.
FC�Er,
ERMIT FEES (attach copy of original receipt and provide explanation below).OR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR O,!N PERMIT (do not cancel permit).
Permit#:
Site Address or Parcel#: ll-a4a su) ADn- 17ey c
Project Name: SCltJGY 1YQ� ,
Subdivision Name: I.ot #:
EXPLANATION: G S S tom,
Signature: Date:
Print Name: Aowd
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or 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 via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE •
Route to Sys Admin: Date B\ Route to Records: Da B
Refund Processed: Date,,V.4/45- , Invoice Processed: Dat6 B
Permit Canceled: I Date / By Parcel Ta Added: I Date B
1:\Building\Forms\RegPenritAction_ 2314.doc
v
City of Tigard
February 26, 2015
David Booth
3005 N. Pacific Hwy W
Rickreall, OR 97371
Re: Permit No. PFI2014-00098
Dear Mr. Booth:
The City of Tigard has processed a refund for the deposit of fees on the above referenced
permit for the following:
Site Address: 11200 SW Fonner St.
Project Name: Sewer lateral
Job No.: N/A
Refund: ® Check#216547 in the amount of$5,500.00.
❑ Credit card "return" receipt in the amount of$
❑ Trust account "deposit"receipt in the amount of$
Notes: Refund 100% of cash assurance for all work completed and approved.
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 RequestforPemzitAction 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 Reeks for processing of refiinds. Accounts
Parable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: David Booth DATE: 1/19/2015
3005 N. Pacific Hwv W
Rickreall, OR 97371 REQUESTED BY: Dianna Howse
TPAiNSACTION INFORl'vUTION:
Receipt#: 195415 Case #: PFI2014-00093
Date: 11/17/2014 Address/Parcel: 11200 S%`('Fonner St.
Pay tilethod: Check Project Name: Sewer lateral
EXPLAINATION: Refund 1000'a of cash assurance for all work completed and approved.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Customer deposit 100-0000-22000 $3,J00.00
TOTAL REFUND: $5,500.00
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff
If under$12,500 Division Manager AMA
If under$25,500 Department Manager
If under$30,000 City Manager
If over$50,000 Local Contract Review Board
- - FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: B
I:\Building\Refunds\RefundRequest.doe x 09/01/2010