PFI2016-00028 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
a COMMUNITY DEVELOPMENT Permit#: PF12016-00028
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 02/19/2016
Parcel: 1S125DB10100
Jurisdiction: Tigard
Site address: 9600 SW SHADY PL
Subdivision: RAZBERRY PATCH,THE Lot: 21
Project:
Project Description: We're replacing our sad old driveway!While we're at it, it seems smart to replace our cracked/poorly
patched approach.
Owner: FEES
Description Date Amount
PHONE:
Contractor:
STAR FLATWORK LLC
14654 SE BERRY CANE LN
DAMASCUS, OR 97089
PHONE: 503-481-1174
FAX:
Applicant:
DAVE CREPEAU
9600 SW SHADY LN
TIGARD, OR
PHONE: 503-568-2611
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: Not Present
Issued By: �_ Si,
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12016-00028
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/1 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/1 06-NOTICE TO COMMENCE WORK Applied Notice
The applicant shall notify the City's Inspector, Kenny Fisher at 503-816-6146 or 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/1 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/1 09-OTHER Applied Notice
City of Tigard
s
PUBLIC ky,"ORhS — ENGINEERING
Public Facility Improvement (PFI) Permit
DESCRIPTION OF WORK (in the right-of-way) TYPE OF WORK
Chcck one: ❑ Utility Connection ❑ TYPE 1 —Franchise Utihty Mork
Sidewalk/driveway approach
Work performed by NV(N,PGE
❑ Street improvements p and/or utility agency.
Detailed description: C-2!ie CZ
TYPE 2—Sidewalk/DrivewaN•/Sewer
Work performed for the purpose of:
CVn0.(-t ky C�91Aet �t^<- Cr ,e-Ved wY�rt tG�6T ' Sidewalk installation or repair.
c �T • Driveway approach installation
Propertv address/location(s): and/or repair
1 1,rd • Sanitaty sewer lateral installation
and/or main line tap
❑ TYPE 3-Full scale Development
Applicant: Work performed with Land use
approval which includes any of
Address: CfC7C.�b � t the following:
Cit}/state: ( �GGf oZI Lip: ��2��_ • Subdivisions or Partitions
Phone:552>_S S68 Zl4 V Email: GoJ1cre_pzGLA • Street widening
Contact name: 'Da.Ve Phone: 50-� S(.3 ` Mainline installation for Sanitary
sewer,Storm sewer,Tigard water
Contractor: St;Gt— F6kt 1orlC LLC_ and/or Tigard Water Service area
CCB#: [Zr-> lVg Expiration: 5-11-z 11G SUBMIT COMPLETED APPLICATION TO:
Address: SE rr\/ LAJ City of Tigard
City/state: QA Zip; 9"7Cba"1 Planning/Engineering
Phone: 'S� �JAl lIZy Email: e '(. C-o�, 13125 SW Hall Blvd.
� Tigard,OR 97223
Contact name: _(Al4�tt.� Phone: 3 (iZl 1C7� Applications for"minor work in right-of-wa%"
only may be emailed to:
Engineer: KA- rownermits&tigard-ongov
Address:
City/state: Zip; FOR STAFF USE' ONLY
Phone: Email: Case No.: 1>Fa-20 1 to -Doo Zg
Contact name: Application submittal fee: 0
Additional fees:
Estimated value of work is required(if over$5,000):S �,�,Vt'� Applicaur a � I)ate-
Application1�wed:
ed:
(varithin the public right-of-wav) B}: r
Is work related to a LAND-USE DECISION? El Yes ,a No �� 2-alit,: Dare:
If so, please specify (MLP, SDR, SUB, etc.) case #:
Applicant otitied:
Is work related to a BUILDING PERMIT? El Nes L�No B} � Date: �2 he
If so,please specify(BUILDING PERMIT)case#: '""""N\Ma%T•0%\LAodUe Applications a«,07/oe2015
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www:tigard-or.gov a 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 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. 'Me 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 jinposed upon 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 each owner of the subject property required.
Applicant/Authorized Agent's signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Bbd. • Tigard,Oregon 97223 • www dgard-or.gov 503-718-2421 • Page 2 of 4
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