PFI2017-00079 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
t COMMUNITY DEVELOPMENT Permit#: PF12017-00079
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 05/02/2017
Parcel: SEG3653
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Alpha Environmental Services, Inc.
Project Description: Spot repair in right of way and street for pooling
Owner: FEES
Description Date Amount
PFI Permit Fee 05/01/2017 $300.00
PHONE:
Contractor:
PHONE:
FAX
Applicant:
CHRISTIAN TROTMAN
11080 SW ALLEN BLVD, STE. 100
BEAVERTON, OR 97005
PHONE: 503-449-6601
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.
Permittee/Applicant
Signature: r/(IP,dMI
LAIssued By: V
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12017-00079
Ty De: 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/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/[ 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. Jonny Gish 971-713-0281 or email jonny@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
RECEIVED
City of Tigard APR 2 5 2017
PUBLIC WORKS— ENGINEERING
Public Facility Improvement (B41AM6
4 4 gip.
DESCRIPTION OF WORK(in the right-of-way)
❑ TYPE 1—Franchise Utility Work
Check one: ES Utilities ❑Sidewalk/driveway approach ❑Street improvements performed by NWN, PGE
Detailed description: Sp2T a.e r i r, _ C.4a kr o f w�l and/or utility agency.
❑ TYPE 2—Sidewalk/Driveway/Sewer
Work performed for the purpose of:
- Sidewalk installation or repair.
- Driveway approach installation
Property address/location(s): k911<7-7 Sgw and/or repair
- Sanitary sewer lateral installation
and/or main line tap
❑ TYPE 3—Full scale Development
Applicant: 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
AContractor: le-1,1- En v i et,a„ 4Lv1Z a M 1 sewer, Storm sewer,Tigard water
and/or Tigard Water Service Area
CCB#: Is-? QV Expiration:
Address: 110"60 5-40 o_tles% Q 1 vt)— S4-i T Loo $ i i 1 rv'
City/state: fO fU,-.Ver X6,,, o R_ Zip: el-X d,S- City of Tigard
Phone:so$ `I`I?66U� Email:(,Tc*T—,-, 0-MA6- 2,ltuin wt++ o l•►s f Planning/Engineering
13125 SW Hadi Blvd.
Contact name: 0-h t•;S Phone: 1&o'9y Hq (06o 1 Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer:
only may be emailed to:
ro�ermits@ajgard-or.�ov
Address:
City/state: Zip:
Phone: Email: Case No.: 7
Contact name: Application submittal fee: # 31�'10- 4
Additional fees:S
sv
Estimated value of work is required(if over$5,000):$ 7. c7 o Application ai cepred:
(within the public right-of-way) By: �� Date:
Is work related to a LAND-USE DECISION? ❑ Yes �{( No Application reviewed:
If so,please specify(MLP,SDR,SUB,etc.) case#: By: iLV Date:
Ll
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes CX No By: hit. Date: ��
If so,please specify(BUILDING PERMIT)case#: '\EW\°"'"w°°"""°"'\pr'-'°°"o"°" "°".wrwaor6
City of Tigard - 13125 SW Hall Blvd. - Tigard,Oregon 97223 - www.tigard-or.gov - 503-718-2421 1 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 franc se with the City of Tigard,when the owner and the appkcant 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
props .
• 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
req . men for approving or denying the application.
��►i:s `co.., �rcaTy►ao.tn t� �l 7
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
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NOTE:
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2. JOINTS TO BE TACK AND SANDED.
3. SAWCUT SHALL BE TACK COATED WITH BITUMINUS ASPHALT EMULSION.
CITY OF TIGARll APPROVED BY: NO SCALE
OREGON MICHAEL A. STONE, P.E. TRENCH
ENGINEERING DIVISION
aTY ENar1EER DWG. N0.
. PUBLIC WORKS DEPARTMENT
S.W.HALL BLVD.
TIG ^O
TIGARD,OREGON 97223 JANUARY 2013 BACKFILL VOICE:
VOICE:(503)639-4171
FAX: (503)684-7297 1APPROVAL DATE
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