PFI2016-00030 I CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12016-00030
13125 SW Hall Blvd., Tigard OR 97223 503.718.2421 Date Issued: 02/24/2016
Parcel: 1 S 136AA01201
Jurisdiction: Tigard
Site address: 6919 SW OAK ST
Subdivision: None Lot: None
Project:
Project Description: Sewer tap for new residence at 6919 SW Oak St
Owner:
FEES
Description Date Amount
PHONE: PFI Permit Fee 02/24/2016 $300.00
Contractor:
STRAUSS EXCAVATING
3617 SW 229TH AVE
BEAVERTON, OR 97007
PHONE 503-649-8117
FAX
Applicant:
JEFFLUEDLOFF
22275 SW SHOLLS SHERWOOD RD
SHERWOOD, OR 97140
PHONE. 503-349-4326
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.
Permittee/Applicant
Signature:
Issued By:
Special Conditions(See Attached)
Note: THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
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, <Insert Name>at<Insert
Phone#>, to establish a preconstruction meeting.
PFI_Utilities 17-NOTICE TO COMMENCE WORK Applied Notice
The applicant shall notify the City's Inspector, Kenny Fisher at 503-816-6146, 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
RECEIVE®
City of Tigard FEB 18 2016
PUBLIC WORKS — ENGINEERING
L CITY OF TIGARD
Public Facility Improvement (PFI) r ENGINEERING
DESCRIPTION OF WORK(in the right-of-way) TYPE OF WORK
Check one:Xutility Connection ❑ TYPE 1-Franchise Utility Work
❑ Sidewalk/driveway approach Work performed by NWN,PGE
❑ Street improvements and/or utility agency.
cY•
Detailed description: zt,4 A;Vz_ TYPE 2-Sidewalk/Driveway/Sewer
Work performed for the purpose of:
- Sidewalk installation or repair.
/ • Driveway approach installation
Property address/location(s): &9_1 V <1,3 Owe air
ZSanitary ewerlateral insta a "on
ain line tap
❑ TYPE 3-Full scale Development
Applicant: /Lt TT^ N`, a w-e= --N Work performed with Land use
approval which includes any of
Address: ,2 2?Z S_ `X-s ���h,o(tS 'Sh�--v�--»o.-�o �. the following:
City/state: /t.*rt�,� o c'�k- Zi 7 Y�
� p • Subdivisions or Partitions
Phone:5o3 Email:'7'Ef-± 9) &LrrAt-qth+ .Sl -•c�� • Street widening
Contact name: Phone:`5s3'3`l9-'-fl 2(. • Mainline installation for Sanitary
�
_ sewer,Storm sewer,Tigard water
Contractor: J`�tC -tJs it and/or Tigard Water Service Area
CCB#: --A72-5:2 5-- Expiration: SUBMIT COMPLETED APPLICATION TO:
Address: 7/ :. 1'a& City of Tigard
City/state: >AC Zip: lcro 7 Planning/Engineering
Phone: Va 3 -6 Y9-_R1/7 Email: 13125 SW Hall Blvd.
' Tigard,OR 97223
Contact name: Ag Phoneme -79.7I`t 77 Applications for"minor work in right-of-way"
only may be emailed to:
Engineer: rogp rmi s ,ggard-or�jZov
Address:
City/state: Zip:
Phone: Email: Case No.:11=.Z22011t -Mo 9r0
Contact name: Application submittal fee: OD
:Additional fees:
Estimated value of work is required(if over$5,000):$ �� '� Applicati n epted:
(within the public right-of-way) By:c�C1� Date:41-11"—1
&
Is work related to a LAND-USE DECISION? El Yes
rewed:
Yes No Zoll
: Date:
If so, please specify (MLP, SDR, SUB, etc.) case #: By
Applicant notified:
Is work related to a BUILDING PERMIT? UK Yes ❑ No By: Date:
If so,please specify(BUILDING PERMIT)case#: M57_1Zo'517 X 07 I'\CURPLN\Masters\Land Use Appla flons Rev 07/09/2015
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 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 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 may be attached to or imposed upon the subject properrr.
• 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.
pplicant/Ruth ed Agent's signature Print name Date
/� - ► ErfC, L,-(0,0
wner's sig r 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 Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov 503-715-2421 • Page 2 of 4
DEVELOPMENT ENGINEERING FEES FOR STAFF tiSFE ONLY
Public Facility Improvement(PFI) Permit: DETAILED
SUBMITTAL
APPLICATION FEE REQUIREMENTS
Part 1: Required submittal fee$300.00
FRANCHISE UTILITY AND SIDEWALK/
PERMIT FEE DRIVEWAY AND CONNECTIONS,ETC.UTILITY
Part 2: All non-water system improvements (work in the right of way)
Engineer's estimate X 5% (less$300.00 submittal fee)
Engineer's estimate X 2%Plan Review Sketch
(including information below)
WATER SYSTEM FEE
❑ Dimensions
Part 3: All public water system improvements
Engineer's estimate X 12% El-Street Name
❑ Site Address
PFI Permit Fee Exemptions:
There will be no permit fee charged,or assurance required FULL SCALE DEVELOPMENT
for the following types of work: (,Subdivisions/Partitions and Street Improvements)
• Sidewalk repair (less than 20 lineal feet)
• Relocate or replace mailbox Design Plans
• Ditch cleaning that does not involve regrading. (6 sets,24x36 or 2204)
• Weephole repair ❑ Cover—Site,Vicinity,Abbreviation,Legend
• Curb repair or replacement (less than 20 lineal feet) ❑ General Notes (City,Water,Sewer,etc.)
• Lawn sprinkler system installation or repair ❑ Street(Plan,Profile)
• Street tree pruning or planting ❑ Water,Storm and Sanitary(Plan Profile)
• Planter strip landscape maintenance ❑ Water Quality Facilities
• Test wells ❑ Grading
❑ Landscaping/Tree Plan
❑ 7Corriposite Utility"Plan (Electrical,Phone,Gas,
Note: A cash assurance may be required per Storm,Sanitary,Water,Signage,Street Lights,etc)
TMC 15.04.140. (customer deposit) ❑ Details
❑ Traffic Sight Distance
❑ Signing and Striping
❑ Street Light Plan and Photometric
❑ Engineers seal/signature
❑ .Sheet label(project land use name,revision and
plan log block,dates and sheet numbers.)
Additional Submittals
(per.Land Use conditions)
❑ Traffic Report
❑ Storm water Drainage Calculations
❑ Geotechnical Report
❑ Preliminary Access Report(Sight Distance)
❑ Proposed Plat
❑ Pathway Design (if applicable)
❑ Water Department Approval
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
SAMPLE SKETCH:
? C" .9 L
Edge of Pavement
Ditch
Streetlight I �•�•— •—'� • •� �r� •—
/ I • e• Ran Dieu,
r
j i"tai—07.6 e1w�iTilS>3--
jExisting House
t� I Existing I
i Driveway
01
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jI v�e
di
o,s
of I
Existing Shop
L_
Powerpole I o o
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IopertpL —-—-—-—-—-
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Hydrant(FH)
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Scale: "I"=30'
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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
ll/W apron (sewer,water, storm)
�rr�r -— nr•�r
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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22275 SW Scholls-Sherwood Road • Sherwood, OR 97140
503-628-3518 • 503-628-5421 Fax • brittanyhomesinc@verizon.net
Page 84 2011 Edition
J—.
Stationary Lariesure with Flagging.::,' �'. Diagrarri 320
Diagram 320 covers total closure of one lane of a two-lane, two-way
roadway. See the detail inset for the layout if using a single flagger to control
both directions of traffic on low volume roads(less than 400 ADT)with good
sight distance as discussed below.
1. Use truck-mounted flashing warning lights on work and protection
vehicles. See Section 4.3—Lights and Lighted Signs for exceptions.
2. For added visibility, a truck-mounted arrow board or PCMS in caution
mode may be used.
3. Flaggers at each approach are required if any of the following
conditions exist:
a. Night Operations.
b. Work space is over 200 feet in length.
c. Sight distance is less than 750 feet from each approach
through the lane closure.
d. Traffic volumes are greater than 400 ADT.
4. The length between the Flagger Ahead signs shall not exceed one
mile. Use Diagram 340—Lane Closure with Pilot Car if exceeding one
mile.
5. Cones should be used to outline the work space when curves or other
roadway alignments prevent clear direction for the motorists to pass
the work space safely.
6. Cones along the work space are recommended when posted speeds
are 45 mph or greater, when working under heavy traffic or when travel
lanes are narrower than 11 feet.
7. Extended queue signing (see Diagram 5-4) should be used when
traffic queues extend beyond the initial advance warning sign.
8. When flagging near an intersection, the "Flagger Ahead" (CW23-2)
sign should be visible to traffic entering from any side road. Additional
advance warning and Flagger Ahead symbol signs may be placed on
the side road(s).
9. Sign set-up and flagger placement shown may be used for intermittent
full road closures of 20 minutes or less.
10. The"ONE LANE ROAD AHEAD" (W20-4) sign is optional and should
be considered on high volume or high speed roads, or when extended
queues are expected.
Chapter 5 December 2011
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Protection Vehicle
ROAD w/TMA(both Optional)
WORK See Chapter 4
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ROAD TO STOP Two Flagger Operation
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