PFI2017-00039 n CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PFI2017-00039
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 03/15/2017
Parcel: SEG891
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Flying H Sewer Repair
Project Description: Adjacent to 12047 SW Pacific Highway. Repair sanitary sewer lateral along SW Center Street. SEG 891
Owner: FEES
Description Date Amount
PFI Permit Fee 03/15/2017 $300.00
PHONE:
Contractor:
FLYING H CONSTRUCTION CO
PO BOX 2533
WILSONVILLE,OR 97070
PHONE: 503-925-1280
FAX: 503-678-4221
Applicant:
ROB MEISNER
PO BOX 2533
WILSONVILLE, OR 97070
PHONE. 503-969-9247
Total $300.00
Please sign below to indicate acceptance of conditions and return a copy with the proposed work schedule along with names and contact
information of responsible parties before b work.
Permittee/Applicant x �{/,
Signature: (/
Issued By: �—
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
RECEIVED
City Of Tigard MAR 15 2017
PUBLIC WORKS — ENGINEERING
' CITY 0F TIGARD
Public Facility Improvement (PFI) jW*GINEERING
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
❑ TYPE 1—Franchise Utility Work
Check one: X Utilities ❑Sidewalk/driveway approach ❑ Street improvements performed by NWN, PGE
Detailed description: and/or utility agency.
Repair sanitary sewer lateral ® TYPE 2—Sidewalk/Driveway/Sewer
Work performed for the purpose of:
• Sidewalk installation or repair.
• Driveway approach installation
Property address/location(s): 1 and/or repair
12047 SW Pacific hwy Tigard 5E./�� l • Sanitary sewer lateral installation
and/or main line tap
Applicant: Flying H Construction ❑ TYPE 3—Full scale Development
PP Y� Work performed with Land use
Address: PO Box 2533 approval which includes any of
City/state:Wilsonville Zip: 97070 the following:
Phone: Email: Rob@f lyinghconstruction.com , Subdivisions or Partitions
Contact name: Rnh MPisnPr Phone: 503 969 9247 • Street widening
• Mainline installation for Sanitary
Contractor: Flying H Construction sewer, Storm sewer, Tigard water
and/or Tigard Water Service Area
CCB#: 104699 Expiration: 2/4/18
Address: Po Rnx 95T'l SUBMIT COMPLETED APPLICATION TO:
City/state: Wilsonville Zip: 97070 City of Tigard
Planning/Engineering
Phone: 503 7$n 491 R Email: Phil @4lyinghmnstruction-ca m 13125 SW Hall Blvd.
Contact name: Phil Rissel Phone:503 780 4916 Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: only may be emailed to:
r� rmits_xigard-or.gov
Address: 61�
Ei
City/state: Zip:
Phone: Email: Case No.: 201-1—W0'fl
Contact name: Application submittal fee: $ 36C --
Additional
6C - -
Additional fees: $
Estimated value of work is required(if over$5,000):$ 7000.00 Application accepted:
,J
(within the public right-of-way) By: AIC-C- Date: 3 l511
Application reviewed:
Is work related to a LAND-USE DECISION? ❑ Yes $I No By.J Date: 3 /S I
If so,please specify (MLP,SDR,SUB,etc.) case#:
Applicant notified:
Is work related to a BUILDING PERMIT? El Yes IN No By: ! Q, Date:
If so,please specify(BUILDING PERMIT)case#: 1:\ENG\Fermit4plicatfon:\pfi—•ppuotlon Rev.12/16/2016
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,if
required by the city pursuant to TMC 15.041.140.
* With the exception of a utility operating pursuant to a valid franchise with the City of Tigard,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. Franchised
Utilities are not required to obtain the owner's signature on the application
BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT:
• The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the ILC-t-
propeM.
o e
• 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 any 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.
Rob Meisner 3/14/17
Applicant/Authorized Agent's signature Print name Date
SIGNATURES of each owner of the subject property, if required.
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 Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 2 of 4
SAMPLE SKETCH:
Edge of Pavement
I -d*— Ditch — `
Streetlight —-—-—-—-—-—-— —r---
I I '
' T—propos d~Se1we�T'irie" �
a'
I� Existing House� I Existing
rl I 21 Driveway 0
CI w �/1•
L I �1
I I r
3,
a I I Jy
w
0
Existing Shop
Powerpole 1 I o a
!� 2
95,
- - -------Roper jLine-------�---
� I
1
F+r Hydrant(FH)
I � I
Scale: 1"=30'
� � 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 - wwwtigard-or.gov - 503-718-2421 - Page 4 of 4
DEVELOPMENT ENGINEERING FEES 1:011 STAH' t SE, ONLY
Public Facility Improvement(PFI)Permit:
APPLICATION FEE REIQUIREMENTS
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 X 5%(less$300.00 submittal fee) (work in the right of way)
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: FULL SCALE DEVELOPMENT
There will be no permit fee charged,or assurance required
(Subdivisions/Partitions and Street Improvements)
for the following types of work:
• Sidewalk repair(less than 20 lineal feet)
• Relocate or replace mailbox Design Plans
• Ditch cleaning that does not involve regrading. (6 sets,24x36 or 22x34)
• Weep hole 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 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
Conditions for PF12017-00039
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/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 twenty-four(24)hours prior to commencing work, prior to any staged
inspection,and after completing work covered by the permit. Call Jonny Gish at 971-213-0281 orjonny@tigard-or.gov
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/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