PFI2017-00094 d
CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
s COMMUNITY DEVELOPMENT Permit#: PF12017-00094
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 06/15/2017
Parcel: 2S103DB04200
Jurisdiction: Tigard
Site address: 11170 SW NOVARE PL
Subdivision: GENESIS NO.2 Lot: 40
Project: Novare Place Driveway Approach
Project Description: Widen driveway approach as part of replacing existing driveway
Owner: FEES
Description Date Amount
PFI Permit Fee 06/09/2017 $300.00
PHONE:
Contractor:
MAC CONCRETE CONSTRUCTION LLC
20362 SW SKIVER DR
BEAVERTON, OR 97007
PHONE: 503-329-0445
FAX:
Applicant:
ALBERT WIERSEMA
11170 SW NOVARE PL
TIGARD, OR 97223
PHONE: 503-620-9188
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 c'' "
Signature: aJ2i2 tC,—LT(�
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12017-00094
Type: Condition Name: Status: Severity:
PFI_Sidewalk/[ 03-WORK SITE EROSION CONTROL Not Met 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 08-EMERGENCY CONTACTS Not Met 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 01 -WORK SITE REQUIREMENTS Not Met 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 Not Met 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 05-PRECONSTRUCTION MEETING Not Met 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 Not Met 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 @ 971-713-0281 or Jonny@tigard-or.gov
PFI—Sidewalk/1 07-PERMIT/PLAN ON SITE Not Met 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/[ 09-OTHER Not Met Notice
PFI_Sidewalk/[ 04-WORK SITE REPAIRS Not Met 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.
City of Tigard RECEIVEDMAY 2 2 201
PUBLIC WORKS —ENGINEERING
Public Facility Improvement (PFWX REDRING
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
❑ TYPE 1—Franchise Utility Work
Check one: ❑ Utilities ®Sidewalk/driveway approach ❑Street improvements performed by NWN, PGE
Detailed description: !�/i t7 s e✓ 1721✓L c.<JA t! APf'2o/lu4 and/or urilitti agency.
W TYPE 2—Sidewalk/Driveway/Sewer
Work performed for the purpose of:
• Sidewalk installation or repair.
• Driveway approach installation
Property address/location(s): 1 1/?0 S' L-v, AJL3✓.42.F_ foi- CIL and/or repair
• Sanitary sewer lateral installation
and/or main line tap
Applicant: 4L%c2T t,,//E,2ser/Ylli ❑ TYPE 3—Full scale Development
Work performed with Land use
Address: Y/1 '70 S.LJ, ND✓,/12� �i �FCE approval which includes any of
City/state: T_1 6st2l7 Zip: cr 7ZZ3 the following:
Phone: ;203•b20 -`i18Email: CR6-E SZ 6k) 4QL_ , C,D • Subdivisions or Partitions
• Street widening
Contact name: AL(,�E/LT L✓i�2z r�A Phone: So3 (�Z 0• `�/Bf3
• Mainline installation for Sanitary
Contractor: M 4G LLC sewer, Storm sewer, Tigard water
and/or Tigard Water Seance Area
CCB#: I � (o �1 + Expiration:
Address: '2 0 3 C,2 S w. S7kiVir 2 D SUBMIT COMPLETED APPLICATION TO.
City/state: -7-0 n,/ Zip: g -2o67 City of Tigard
Planning/Engineering
Phone: Y/>tfkrv. 'L+ 13125 SW Hall Blvd.
Contact name: C2,e-5 C_S/t/Cj0 Phone: 5-0 3-3 Zct - V 44S Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: only may be emailed to:
rowperrnits(a ti"d-or.gov
Address: ��FOR STAFF USF. ONIN
City/state: Zip: j
Phone: Email: Case No.:
Contact name: Application submittal fee: $3ao•d 0
Additional fees: $
Estimated value of work is required(if over$5,000):$ Application accepted:
(within the public right-of-way) By: Date: ec3 r
Application reviewed.-
Is
eviewed:Is work related to a LAND-USE DECISION? ❑ Yes ❑ No r"
Date:
If so,please specify (MLP,SDR,SUB, etc.) case#: B �
y.JGsi
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes ❑ No By: Date:
If so,please specify(BUILDING PERMIT)case#: 1.\EnG\Perm+tnppkatlmnsyfl_applkation Rev.12/16n016
Cityof Tigard • 13125 SW Ball Blvd. • Tigard,Oregon 97223 • ww wtigard-or.gov • 503-718-2421 0 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 arc different
people,the applicant must be the purchaser of record ora 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 my recorded deed restrictions that may be attached to or imposed upon the subject
roe T.
• 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.
�L��rc-✓� "1./ ` A i r3 E2 i L✓ 2C�/+i/J 5� 2 Z ?
Applicant/Authorized Agent's signature Print name Date
SIGNATURES of each owner of the subject property,if required.
44-g�2r l�t��r S' z 2-
Owner's
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 503-715-2421 • Page 2 of 4
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Picklist for Work Order Nbr 30456
PICKLISTS 18 JAN 2017
Page: 1 10:56:24AM
User: AL
Part Nbr: 44703-5 Mfg Part Nbr: 44703-5 Mfg Qty: 1 Release Date: 01/17/17
Description: DOOR-ACCESS Revision: Minimum Qty: 1 Finish Date: 03/31/17
Std Labor Hrs: 0.50
Component Part Nbr Description Revision UM Warehouse/Location Operation Req Qty Pick Qty Issue Date Comp
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EXISTING DRIVEWAY —
MATCH WIDTH & GRADE
A
R/W LINE
SEE NOTE 3
VARIES
�2% SEE 12%
5' MIN 2� NOTE 3 1r SIDE WALK
SEE NOTE 2 A
30' MAX
6' 6'
10' MIN
PLAN
3/4" PROJECTED TOP R/W
OF CURB 691
27 MAX
STREET :a
o,• ode�,•ao o. . . ;: °� : .a OR��FIA'
C) o0 Oo •' • rVq'
0 O o 0 o c o°o°0 080' o•o°o
O O o O • ° °
Ooo O O O
2" OF AGGREGATE
SECTION A—A (3/4"-0") COMPACTED
NOTES:
1. CONCRETE COMPRESSIVE STRENGTH SHALL BE A MINUMUM OF 3000 PSI AFTER 28 DAYS.
2. CURB JOINT SHALL BE TROWELED WITH A MIN 1/2" RADIUS ALONG BACK OF CURB.
3. EXPANSION & CONTRACTION JOINTS SHALL BE 1/2" PREMOLDED ASPHALT IMPREGNATED
MATERIAL OR EQUAL EXTENDING FROM SUBGRADE TO FINISH GRADE.
4. SEE STD DETAIL NO. 146
Cin'0F TIGARD APPROVED BY: NO SCALE
c)xGcc)D MICHAEL A. STONE, P.E. STANDARD DRIVEWAY
ENGINEERING DIVISION
PUBLIC WORKS DEPARTMENT CITY ENGINEER STANDARD NO.
IGARD,OREGOBLVD.
N97M JANUARY 2013 w/CURB-TIGHT SIDEWALK 142
VOICE:(503)639-4171
FAX: (503)684-7297 APPROVAL DATE