PFI2017-00047 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12017-00047
13125 SW Hall Blvd., Tigard OR 97223 503.718.2421 Date Issued: 03/27/2017
Parcel: 2S104AA04300
Jurisdiction: Tigard
Site address: 12320 SW 127TH AVE
Subdivision: BELLWOOD Lot: 23
Project: Bonnono Sidewalk
Project Description: Sidewalk and driveway replacement for 12320 SW 127th Ave.
Owner: FEES
Description Date Amount
PFI Permit Fee 03/27/2017 $300.00
PHONE:
Contractor:
TUALATIN VALLEY CONCRETE CORP
8950 SW LOCUST STREET
TIGARD, OR 97223
PHONE: 503-891-0955
FAX:
Applicant:
BRETT WEINEL
8950 SW LOCUST STREET
TIGARD, OR 97223
PHONE: 503-891-0955
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.
Perm itteelApplicant
Signature: f �
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12017-00047
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 Ken Fisher at 506-816-6146 or Kenny@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/[ 09-OTHER Applied Notice
RECEIVED
City Of Tigard MAR 2 2 2017
PUBLIC WORKS — ENGINEERING CITY OF TIGARD
_ PLANNING/ENGINEERING
Public Facility Improvement (PFI) Permit
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
❑ TYPE 1—Franchise Utility Work
Check one: ❑ Utilities a Sidewalk/driveway approach ❑Street improvements performed by NWN, PGE
Detailed descrition: RGA! S/ de &/a 1k' t C U4 RtiO4 and/or utility agency.
❑ TYPE 2—Sidewalk/Driveway/Sewer
Work performed for the purpose of:
• Sidewalk installation or repair.
Z•Z O l '-7 installation address/location(s): Z3 W l L • Driveway approach installaand/or repair
NVL D Jd to, A 0 re L :Z 2Z 3 • Sanitary sewer lateral installation
(/^ ,," ��,�p and/or main line tap
Applicant: _/t Iyjyl.� l_ entyR � F� ❑ TYPE 3—Full scale Development
pP Work performed with Land use
Address: approval which includes any of
City/state: Zip: the following:
Phone: Email: • Subdivisions or Partitions
Contact name: Phone: • Street widening
• Mainline installation for Sanitary
Contractor: —rL/ A ��I t/c ' e /vepie r e7e sewer, Storm sewer,Tigard water
CCB#: .S 2 8 and/or Tigard Water Service Area
xpiration:
Address: '6456 G/ rV 6 C V s t SUBMIT COMPLETED APPLICATION TO:
City/state: ti q h rck 0 r iC Zip: 7 -72-2-3 City of Tigard
Phone: Email: Planning/Engineering
C 13125 SW Hall Blvd.
Contact name: !'l2. Wer nPhone:
56-3-- 71 Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: only may be emailed to:
romTermits a,tigard-or.gov
Address: FOR STAFF- USF ONLN
City/state: Zip: _
Phone: Email: Case No.:KI 201-7 - Doo L-I
Contact name: Application submittal fee: $300.00
Additional fees:$
Estimated value of work is required(if over$5,000): Application accepted:
(within the public right-of-way) By:_ Av-- Date:3 2� 1
Application reviewed:
Is work related to a LAND-USE DECISION? ❑ Yes ❑ No TG, (v Date:
If so,please specify (MLP,SDR,SUB,etc.) case#: By:
Applicant notified:
jjq
Is work related to a BUILDING PERMIT? ❑ Yes ❑ No By: AV- 9 Date: 2'
If so,please speeif,(BUILDING PERMIT)case#: l:\ENG\PermitApplications\pfi application 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 utiliq,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 owners 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 subject
ro 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.
&-to- �1-c f f G & ZZ-17
App cant/Authorized Agent's signature Print name Date
SIGNATURES of each owner of the subject property, if required.
Owners signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
Cit} of Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwctigard-or.gov 503-718-2421 • Page 2 of 4
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