PFI2016-00152 �+ CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
awCOMMUNITY DEVELOPMENT Permit#: PF12016-00152
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 07/20/2016
Parcel: 2S 101 AC01900
Jurisdiction: Tigard
Site address: 12615 SW 72ND AVE
Subdivision: None Lot: None
Project: Lowe's Sidewalk Repair
Project Description: Replace broken sidewalk at sanitary manhole
Owner: FEES
Description Date Amount
PHONE:
Contractor:
SDB, INC.
212191 NW CHERRY LANE
HILLSBORO, OR 97124
PHONE: 503-601-9065
FAX:
Applicant:
KEVIN KELLEY
212191 NW CHERRY LANE
HILLSBORO, OR 97124
PHONE: 503-601-9065
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: ��
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
J
Conditions for PF12016-00152
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/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/[ 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/[ 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 twenty-four(24) hours prior to commencing work, prior to any staged
inspection, and after completing work covered by the permit.
PFI—Sidewalk/1 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
RECEIVE®
JUL 19 2016
City of Tigard
CITY OF TIGARD
= PUBLIC WORKS — ENGINEERING PLANNINC"71SIGINEERING
Public Facility Improvement (PFI) Permit
DESCRIPTION OF WORK(in the right-of-way) TYPE OF WORK
Check one: ❑ Utility Connection ❑ TYPE 1—Pranchise Utility Work
X Sidewalk/driveway approach \Cork performed by NWtN,PGE
❑ Street improvemcats l / / and/or utility agency.
Detailed description: ���'��-`E' /'-1P�c/1 J/y c'<<��//' ;VTI.TE 2—Sidewalk/Driveway/Sewer
2-1 V m a.411 41n10- Work performed for the purpose of:
• Sidewalk installation or repair.
�j/ • Driveway approach installation
Property address location(s):
/2 41-.! SCJ 71? /7✓C and/or repair
g • Sanitary sewer lateral Instailatlon
/ � Z and/or main line tap
❑ TYPE 3—Dull scale Development
Applicant: \York performed with Land use
1 P approval which includes any of
Address: the following:
City/state: Zip: • Subdivisions or Partitions
Phone: Finail: • Street widening
Contact name: Phone: • Mainline installation for Sanitary
sewer,Storm sewcr,'Tigard water
Contractor: ��G and/or Tigard Water Service Area
CCB#: //`'S%69� Expiration: ��J' L SUBMIT COMPIXTED APPLICATION TO:
Address: 4?1je9/ /l�l✓ may(.,-Q�J6*/moi /_ o e-y City of Tigard
City/state: y�/fro•�o �� Zip: ^/ X12 y Planning/Engiueering
la In�� 13125 SW Hall Blvd.
Phonc:.r�' 410/ `�OS) mail: ��'VOir9. /C�'���r�k- 31 / Tigard,OR 71223
Contact name: v �' I'hOnC: �U-� O0� �f 06S' Applications for"minor work in right-of-way"
only may be emailed to:
rov ernitaiNtigar�d-or guy
Engineer:
Address:
City/state; Zip:
Phone: Email: Case No.:
Contact name: Application submittal fee:
Additional fees:
Estimated value of work is required(if over S5,000):S Application gacccepted;
(within the public right-of-way) By: Date:_-= =L-,�11(e
Application reviewed:
Is work related to a LAND-USE DrCISION? Cl Yes Naim nate: 7-'_-M
gy; 14
If so,please specify(MLP,SDR,SUB,etc.) case M Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes A No Byt�— Date:
If so,please specify(BUILDING PERI1417)case M h\NNPtN\1Aissen\lsndUseAppl,c,ewns we�.o»o9��ots
City of Tigard 13125 SW Hall blvd. 'Tigard,Oregon 97223 • www.dgard-or.gov • 503-718-2,121 • Page 1 of 4
Z�6 5 -_�,fW 9V " //,If, 1 ,'fL-T-
APPLICANTS
NOTE: Person specified as`Applicant"shall be designated"Permittee"and shall provide financial assurance for work.
Whm the owner and the applicant are diffc rent 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 owncr(s)most 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 clots not violate any deed restrictions that may be attached to or imposed upon the subject propertt.
• If the application is granted,tate applicant will exercise the rights';ranted 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 du•application,including the policies and criteria,and understands the
requirements for approving or denying the application.
SIGNATURES of tach owner of the subject property required.
ell
r i
�A'le 7
App icant/Authorized Agent's signature Print name Date
Owner's signature Print name Datc
Owner's signature Print name Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SVI Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2121 • Page 2 of 4
DEVELOPMENT ENGINEERING FEES ;FQ1CfS,AkFJ7 USE ONLY
Public Facility Improvement(PFI)Permit: 1J p
APPLICATION FEE
Part 1: Required Submittal fee$300.00
FRANCHISE UTILITY AND SIDEWALK/
PERMIT FEE DRIVEWAY AND UTILITY
Part 2: All non-water system improvements CONNECTIONS,ETC.
Engineer's estimate K 5% (less 5300.00 submittal fee) (work in the right of may)
Engineer's estimate l 2%Plan Review Sketch
(including information below)
WATER SYSTEM FEE ❑ Dimensions
Part 3: All public water system improvements ❑ Street Mame
Engineer's estimate 1 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)
• Sidewalk repair(Icss than 20 lineal feet)
�• Relocate or replace mailbox Design Plaits
• Ditch cleaning that does not involve regrading. (G sets,2406 or 22x34}
• Weepholc 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 ❑ Witer Quality Facilities
• Test wells O Grading
❑ Landscaping/Tree Plan
❑ Connposite Utility Plan(Electrical,Phone,Gas,
Note: A cash assurance may be required per Storm,Sanitary,\\fuer,Signage,Street Lights,etc)
TMC 15.04.140.(customer deposit) ❑ Details
❑ 'Traffic Sight Distance
❑ Signing and Striping
❑ Street Light Plan-and Photometric
❑ fingincets seal/signature
❑ Sheet label(project land use name,revision and
plan log block,dates and sheer numbers)
Additional Submittals
(per land Use conditions)
❑ Traffic Report
❑ Sturm 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 • 503-718-2.121 • Page 3 of 4
SAMPLE SKETCH:
Edge of Pavement
Ditch —1110"
n Streetlight I — —•—•—•---•—•—r—•—
TRain yr t„
' a
o
' i"P'roj�os f'S�eiYrie"
W
�, I ;U Existing House
I Existing 1
�1 II Driveway
0
00
Existing Shop
Powerpole
I 1-----•—•
Property nti------�---
, o
II Fire Hydrant(FH)
I
I I I
Scale: 'I"=30'
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MINIMUM SKETCH REQUIREMENTS(Put"N/A"if Not Applicable):
`North arrow —Zf:�'Property lines&dimension (Slope of property
y Street&street name(s) Existing building,structures Utility&street light poles
/,- Proposed work Existing curb or edge 'frees
Existing S/W or of pavement Existing utility locations
D/W apron (sewer,water,storm)
PUBLIC FACILITY IMPROVEMENT PERMIT
Cite of Tigard • 13125 SW }lall Blvd. • 'Tigard,Orcgon 97223 • wwwdgard-or.gov 503-718-2421 • Page 4 of 4
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