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PFI2015-00146 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12015-00146 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 10/15/2015 Parcel: SEG1937, 1940, 2076 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: Rose City Concrete Project Description: Adjacent to 10695 SW Murdock St. Removing&replacing sidewalk around Pacific Crest Apartments. Owner: FEES Description Date Amount PHONE: Contractor: PHONE: FAX: Applicant: MELISSA WINTER 3300 NE 185TH,#183 PORTLAND, OR 97229 PHONE: 503-292-9702 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 e� Signature: Issued By: VIL 0 /��� j 1 l o d aov A (Nr &I �rZ7� C v Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12015-00146 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/1 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/1 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/1 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 Kenny Fisher at 503-816-6146 or email at kenny@tigard-or.gov 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 City of "Tigard p PUBLIC WORKS — ENGINEERING EIFCEIVED • Improvement (PFI) tPublic Fac�ty mp 6F 15 DESCRIPTION OF WORK (in the right-of-way) 'IPAMWWOMNEERING Check one: ❑ Utility Connection ❑ TYPE 1-Franchise Utility Work Sidewalk/driveway approach Work performed by N1VT,1'Gl: r ❑ Street improvements and/or utility agency. Detail---' description: c 1 C,' *TYPE 2-Sidewalk/Driveway/Sewer �" " Work performed for the purpose of: ^i Sidewalk installation or repair. l�i71 ?T, Driveway approach installation and/or repair Property address/location(s): j��5C:_V ^h • Sanitary sewer lateral installation o(v and/or main line tap ❑ TYPE 3-Full scale Development Applicant << �' Work performed with Land use - • ,.-� approval which includes any of Address: n the following- sl ollowing /sl te: _ Zip: Subdivisions or Partitions n . C ,� Email: t ;S Street widening c 7C/ 7_ �� U I 1 • Mainline installation for Sanitary Contact name: _ Phone: .• sewer,Storm sewer,Tigard water Contractor: r 50 Ij and/or Tigard XMtter Service Area CCB#: 4S14-1-7,;— Expiration: 2 ZIIIL,, SUBMIT COMPI.ETEDMPLICATIONTO: Address: %,I, � 1 City of Tigard City/state: 1 ' r Zip: `l]a?�`7' Planning/Engineering 13125 SW Hall Blvd. P : a14 1- q70 Email: " ' �m ti - Tigard,OR 97223 Contact name: P > 2q v' AVX Applications for"minor work in aglit-of-way" i only may be emailed to: 1/ ./I �g�ermitsCa dgard-or.Qov Engineer: l /t Address: City/state: Zip: Phone: Email: Case No.: ,Awcy S-- co (� Contact name: Application submittal fee: Additional fees: Estimated value of work is required(if over$5,000):$ 1 J LCy Application accepted: (within the public right-of-way) By �j Date: 5 Applicata n reviewed: Is work related to a LAND-USE DECISION? ❑ Yes � No By:.-YR Date: 10, 1 S (S­ If so, please specify (MLI,SDR,SUB, etc.) case #: Applicant notified. Is work related to a BUILDING PFRMIT? ❑ Yes `0 No B /�M 1 b Date: l�/�I-1/S If so,please specify(BUILDING PERMIT)case#: 1.\rua"tM•stemu•ndcs.ApOicadms "••.07roWn015 City of Tigard •/13125 SW Hall Blvd. • Tigard,Oregon 97223 wwwtigard-or.gov • 503-718-2421 • Page 1 of 4 S.1�eW A llI► ,,, e 0,,"0- APPLICANTS NOTE: Person specified as"_\pplicant" shall be designated "Permittee"and shall provide financial assurance for work. \C'hen 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 ovtner(s)must sign this application in the space provided or submit a written authorization with this application. BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT: • The above request does not violate any deed restrictions that maybe attached to or imposed upon the subject tn�ertr. • If the application is granted, the applicant will exercise the rights granted hit accordance with the terms and subject to all the conditions and limitations of the approval. • All of the above statements and the statements vh 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 denyuig the application. SIGNIIRES of owner o subject property required. Applicant/ prized ge is signature Print name Date Owners signature Print name Date Owner's signature Print name Date Owner's signature Print name Date �x�-ter'-a ••.. ... _. c;e^: -�.;.:. .°,...;...,.�._ Fb:.ic---.�.m��, a:.a->:<_�M;�y^'�..�-=��.�i�; ..-: -�- �s:�..,,:::.�*M PUBLIC FACILITY IMPROVEMENT PERMIT Cityof Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 972293 • www.tigard-or.gov 503-718-2421 • Page 2 of 4 zc RECEIVED OCT 12 2015 CITY OF TIGARD PLANNING/ENGINEERING