PFI2016-00093 u CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12016-00093
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 05/09/2016
Parcel: 2S 1146610700
Jurisdiction: Tigard
Site address: 16114 SW 104th AVE
Subdivision: SWANSON'S GLEN Lot: 48
Project:
Project Description: Replacing cracked and slumping section of sidewalk(only). Only one section to be replaced. Problem
caused by faulty installation of drain pipe and also fixing drain pipe.
Owner: FEES
Description Date Amount
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
MARK FISHER
16114 SW 104TH AVE
PHONE:
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
00
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12016-00093
Type: Condition Name: Status: Severity:
PFI—Sidewalk/1 01 -WORK SITE REQUIREMENTS 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 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 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/[ 04-WORK SITE REPAIRS 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/[ 05-PRECONSTRUCTION MEETING 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
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.
Use automated inspection request.
PFI—Sidewalk/1 07-PERMIT/PLAN ON SITE 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/[ 09-OTHER Notice
City of Tigard
f
PUBLIC WORKS —ENGINEERING
Public Facility Improvement (PFI) Permit
DESCRIPTION OF WORK(in the right-of-way) TYPE OF WORK
Check one: ❑ Utility Connection ❑ TYPE 1—Franchise Utility Work
Sidewalk/driveway approach Work performed vy NVIN,PGE
❑ Street improvements and/or
and/or utility agency.
Detailed description: Qn^ c ih +t Gh V V t '+� A TYPE 2—Sidewalk/Driveway/Sewer
S, 1 O - Work performed for the purpose of:
1 CC� �`� I [ � Sidewalk-instaliadon or repair.
PC-Uetm C4 bU ��v 1 N �+�C c.��cliarl O�u, D, ,i�?• _71Xt n� . Driveway approach instals tion
AA) A Q CJ and/or repair
Property address/location(s): �iO� S (O� �1 � of } • Sanitary sewer lateral installation
and/or main line tap
❑ TYPE 3—Full scale Development
]Fork performed with Land use
Applicant: MOA,�yy►4A �R'��vT J� approval wluch includes any of
Address: An 9 r1fl�� f'lVP the following-
City/state: 'I` zip: • Subdivisions or Partitions
Phone: — Email: r'llb.�i C'e� lir s O� Sucetwidening
Yk Phone: to • Mainline installation for Sanitary
Contact name: _�
sewer,Storm sewer,Tigard water
and/or Tigard Water Service Area
Contractor: n �
CCB#: Expiration: f SUBMIT COMPLETED APPLICATION TO:
Address: City of Tigard
City/state: Zip:
Pla n n i ng/Engin eeri ng
13125 SW Hall Bhd.
Phone: Email: — Tigard,OR 97223
Contact name: Phone: kpplications for"minor work in fight-of-way"
only may be emailed to:
xo-% rmi+R(a �o�rd-��Oy
Engineer: '-
Address: FOR
City/state: Zip:
?FIZot(,C —odp� 3
Phone: Email: Case No.: _
Application submittal fee:
Contact name:
Additional fees:
Estimated value of work is required(if over$5,000)'.$ h lA Applicati n ac pled:
(within the public right-of-way) Date:
Applica'on eAewed:
Is work related to a LAND-USE DECISION? ❑ Yes No B Date:
If so,please specify(MLP,SDR,SUB,etc.) case #: A licit notified:
pp
Is work related to a BUILDING PERMIT? O les K No By; � Date:
I:\CURPLN\Macon\lend Un,4ppticah�ns Rev 07/09/2015
If so,please specify(BUILDING PERMIT)case#:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • w•w•wtigard-or.gov • 503-718-2421 • Page 1 of 4
APPLICANTS
NOTE: Person sp-- ed 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. "1'he 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 tl a�t may be attached to or imposed upon thesubject nrooerty.
a.
• 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 sd 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.
Ap licant/Auth zed Agent's signature Print name t Date
�w of Zgl7S,
Owner's signature Print name Date
z LIL
jOwnVer' sigg&nature Print name Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • xvww tigard-or.gov 503-718-2421 Page 2 of 4
DEVELOPMENT ENGINEERING FEES -FOR STALFF USE ONLY
Public Facility Improvement(PFI)Permit: DETAILED -
APPLICATION FEE SUBMITTALREQUIREMENTS
Part L• Required submittal fee$300.00
FRANCHISE UTILITY AND SIDEWALK/
PERMIT FEE DRIVEWAY AND UTILITY
CONNECTIONS,ETC.
Part 2: All.non-water system improvements (work is 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 impr9vements
❑ Street Name
Engineer's estimate X 12%
❑ 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)
d • 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) p 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
❑ Composite 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:
SW "y" St
Edge of P avemerd
I -�---
Ditch —�•-
Streetlight, I ._.....—.—._.—.—....rr....—
Ren
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T op d'Se'rTi'ne
Existing 1
Ddveway •
a�
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o• I • •
of
P owrepo 1 I I m 1
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0 Wd I� pit------- gytine 5• —-—-—-—---
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I = I Fire Hydrant(Ft-o
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I Scale: 11"--30'
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MINIMUM SKETCH REQUIREMENTS(Put"N/A"if Not Appheable):
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 • wwwtiga d-or.gov 503-718-2421 Page 4 of 4
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