PFI2016-00209 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12016-00209
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 09/22/2016
Parcel: 2S 102AC00400
Jurisdiction: Tigard
Site address: 9230 SW BURNHAM ST
Subdivision: None Lot: None
Project: Tigard Tap House
Project Description: PFI permit for new driveway approach
Owner: FEES
DOLAN&CO LLC Description Date Amount
BY FLORENCE T DOLAN
4523 NE DAVIS ST
PORTLAND, OR 97213
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
MIKE MILLER
9088 SW HILL ST
PORTLAND, OR 97223
PHONE: 650-422-0572
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: bt '
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12016-00209
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/[ 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 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
RECEIVED
City of Tigard SEP 2 2 2016
_ PUBLIC WORKS ENGINEERING CITY OF TIGARD
. . , G'F„�G'NEERING
Public Facility Improvement I
ermit
DESCRIPTION OF WORK(in the right-of-way) TYPE OF WORK
Check one: ❑ Utility Connection
❑ TYPE l—Franchise t?tility-\Cork
Sidewalk/drieway approach Work performed by N\CN,PGE
❑ Street improvements and/or unlit}'agency.
Detailed description: �h�l-v�S i {/1;V�� t'h' (tet ❑ TYPE 2—Sidewalk/Driveway/Sewer
Work performed for the purpose of:
• Sidewalk installation or repair.
f • Driveway approach installation
a 3 G 5 (Ahtlr0,r" S r and/or repair
Property address/location(s): t
�
• Sanitary sewer lateral installation
` and/or main line tap
/ ❑ TYPE 3—Full scale Development
Applicant: ire / �/ '{� Work performed,ith Land use
S- /f /` approval which includes any of
Address: �� "? [� the following:
CICS/state: d rTy Zip: / • Subdivisions or Partitions
Phone:L90 YA _!L5 j�Email: Phi h-v ze" ►re" "Ve'C Oht • Street widening
Contact name: �Ih;,Lxt" Phone: SU L()',? 05`7;Z • Mainline installation for Sanitary
sewer,Storm sewer,Tigard water
Contractor: A G4 ce-0th and/or Tigard Water Service Area
CCB#: Expiration: SUBMIT COMPLETED APPLICATION TO:
Address: City of Tigard
Cit'/state: Zip: Planning/Engineering
13125 SW Hall Bbd.
Phone: Email: Tigard,OR 97223
Contact name: Phone: Applications for"minor work in right-of-way"
only may be emailed to:
Engineer: rownermits&tigar�or4ov
Address:
Cit}/state: Zip:
Phone: Email: Case No.: 04?0�
Contact name: Application submittal fee:
Additional fees:
Estimated value of work is required(if over$5,000):$ Application accepted:
(within the public right-of-way) By: LS� Date: I�p
Application reviewed:
Is work related to a LAND-USE DECISION? ElYes ElNo
By: �
If so, please specili• (NfLP, SDR, SUB, etc.) case #: I��► '0—) Date:
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes ❑ No By. /—•S Date:
If so,please specify-(BUILDING PERMIT)case#: 1:\CURPIN\Masten\Land Use Applications Rev.07/09/2015
Cityof Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • xt%y%iaigard-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. 'nte 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 prop
• 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.
SIGNAI owner of the subject property required. r�
/III k-e- 10,17,11-er-1
Applicant/Authorized Agent's signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
Owner's signature Print nanle Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • ww wtigard-or.gov 503-718-2421 • Page 2 of 4
DEVELOPMENT ENGINEERING FEES FOR STAFFUSE ONLY
Public Facility Improvement (PFI) Permit:
DETAILED SUBMITTAL
REQUIREMENTS
APPLICATION FEE
Part 1: Required submittal fee$300.00 FRANCHISE UTILITY AND SIDEWALK/
PERMIT FEE DRIVEWAY AND UTILITY
CONNECTIONS,ETC.
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
❑ 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)
• Sidewalk repair(less than 20 lineal feet)
• Relocate or replace mailbox Design Plans
• Ditch cleaning that does not involve regrading. (G sets,24x36 or 22x34)
• 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
❑ Composite Utility Plan(Electrical,Phone,Gas,
Note: A cash assurance maybe 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)
❑ Yater Department Approval
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard 13125 Sub'Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 3 of 4
SAMPLE SKETCH:
Edge of Pavement
I Ditch
Streetlight -I — ----------- —r---
I • e Rain Drain
a
tr
' T--rop'os cf•SawerTirie--
I I -
N�
Existing
Existing House
I I �
Driveway
`al
3 I •
o
d I vop 1
a
�i I 1
> '
Existing Shop �
Powerpole
��► o • o
- -property Li—ne
------ —-—-—-—-—-
I �
� I
Fire Hydrant(FH)
I I I
Scale: 'I"=30'
� I I
I I I
' I I
� � I
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
D/W apron (sewer,water, storm)
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-ongm, • 503-718-2421 Page 4 of 4