PFI2017-00105 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
= COMMUNITY DEVELOPMENT Permit#: PF12017-00105
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: SEG22017
Parcel: EG2278
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Sidewalk Replacement
Project Description: Adjacent to 10650 Summerfield Dr. replacing sidewalk
Owner: FEES
Description Date Amount
PFI Permit Fee 06/13/2017 $300.00
PHONE
Contractor:
PHONE:
FAX.
Applicant:
CARI LINDSEY
10650 SW SUMMERFIELD DR
TIGARD, OR 97223
PHONE: 503-620-0131
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: See application
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12017-00105
Type: Condition Name: Status: Severity:
PFI—Sidewalk/1 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/[ 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/[ 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/[ 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 JUN 13 2017
PUBLIC WORKS — ENGINEERING
T� r
nF TIGPublic Facility Improvement (PFI) eg fn►NG
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
❑ TYPE 1-Franchise Utility Work
Check one: ❑ Utilities �f Sidewalk/driveway approach ❑ Streetimprovements performed by NWN, PGE
Detailed description: and/or utility agency.
TYPE 2–Sidewalk/Driveway/Sewer
Work performed for the purpose of:
�+ • Sidewalk installation or repair.
J�,lrnrn /1�V�(� • Driveway approach installation
Property address/location(s) \�J (� and/or repair
SQ dA X—, *e:A• �–�8) • Sanitary sewer lateral installation
and/or main line tap
El TYPE 3–Full scale Development
Applicant: Work performed with Land use
Address: q1! approval which includes any of
City/state: Zip: �
1 I�athe following:
Phone: Email: tAq5@ CAWn((A q1l •rLd • Subdivisions or Partitions
^ ` 2 partitions- Street widening
Contact name: C(Lh—�` , ��'s'��_ Phone: U .L
• Mainline installation for Sanitary
Contractor: 'CTl l
t��a />�ftk' sewer, Storm sewer,Tigard water
and/or Tigard Water Service Area
CCB#: /�� /� E tration:
Address: {�"L JJ Ckob�xP • sUBMITCOMPLETED APPLICATION TO:
City/state: !�kOK)d CSL. Z. �1\�O City of Tigard
�JD3 ��12��J��jEmail: Planning/Engineering
Phone:
13125 SW Hall Blvd.
Contact name: VI\APi(' Phone: `' .-701-(aGnL Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: only may be emailed to:
rownermitsCa,..tigard-or.gov
Address:
City/state: Zip:
Phone: Email: Case No.: l't-1_[>U17 UC7i
Contact name: Application submittal fee: $ 1-_2 OC) �a
Additional fees: $
Estimated value of work is required(if over$5,000):$��,� Application accepted:
(within the public right-of-way) By:� Date:
Application
Is work related to a LAND-USE DECISION? Yes No ewed:
evi
El Yes
If so,please specify (MLP, SDR,SUB, etc.) case #:
Applicant notified:
Is work related to a BUILDING PERMIT? El Yes No BY:
Date:
I f so,please specify(BUILDING PERMIT)case#: I:\ENG\PermitAppl ations\pfi_appliotlon Rev.12/16/2016
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page I 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 subject
prope
• 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.
a4o-�, � A fAsw CA jC11 L �Id a l,,�
Applica uthorized Agent's lignature Print name Date
SIGNATURE of each owner rbf the property,subject roe ,if re uirei
P nY q
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
DEVELOPMENT ENGINEERING FEES 1-011 STAFF USE ONLY
Public Facility Improvement(PFI)Permit:
DETAILED SUBMITTAL
APPLICATION FEE REQUIREMENTS
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.
(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
Part 3: All public waters stem improvements El Dimensions
P y p El 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)
Design Plans
• Relocate or replace mailbox (G sets,2406 or 22x34)
• Ditch cleaning that does not involve regrading.
• 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 El 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) El 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
SAMPLE SKETCH:
jEdge of Pavement
I Ditch —�
Streetlight I -0•— .............
FY Troe Rain Drain
� a
I � ctiauerer ° 1
� o
' T—'Irf5'ITP)S d'SerTIR� 1
" t10 ai��t8r� •
�� Existing
�I >r ■ Driveway
y U�
g
'
o' I
v
e' � I I e ■
I cry 1
O�
i
Powerpole
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--------7rropertyIne—-—-—-—-—-
� 1
■
I I Fire Hydrant(FH)
� � I
Scale: 1"=30'
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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-or.gov - 503-718-2421 - Page 4 of 4
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