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PFI2018-00067 n CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12018-00067 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 03/19/2018 Parcel: SEG104 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: Clog Busters LLC Project Description: SEG104, Associated with 9350 SW 70th Ave. Repair up to 10' of sanitary sewer located within the city right of way in the street. Owner: FEES Description Date Amount PFI Permit Fee 03/14/2018 $350.00 PHONE: Contractor: PHONE: FAX: Applicant: TRICIA WOLF 2900 SW CORNELIUS PASS RD #549 HILLSBORO, OR 97123 PHONE: 503-730-9775 Total $350.00 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 — r Signature: �� ��l'IC47LO J Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12018-00067 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/[ 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/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. 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/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 MAR 13 2018 City of Tigard CITY OF T!$6 fit 0 PUBLIC WORKS —ENGINEERING PLANNING/ENGINEERING Public FaciImprovement (PFI} PermitTIGARD tY TYPE OF WORK DESCRIPTION OF WORK(in the right-of-way) ❑ TYPE 1—Franchise Utility Work Check one: 21 Utilities ❑ Sidewalk/driveway approach ❑Street improvements performed by NWN, PGE Detailed description: Repair up to 10'of sanitary sewer located within the city and/or utility agency. right of way in the street ® TYPE 2—Sidewalk/Driveway/Sewer Work performed for the purpose of: • Sidewalk installation or repair. • Driveway approach installation Property address/location(s): 9350 SW 70th Ave,Tigard,OR 97223 and/or repair C 10 7- • Sanitary sewer lateral installation and/or main line tap Applicant: Clog Busters LLC El TWE 3—Full scale Development pp Work performed with Land use Address: 2900 SW Cornelius Pass Rd#549 approval which includes any of City/state: Hillsboro,OR Zip: 97123 the following: Phone:503-680-8947 Email:tricia@clogbustersllc.com • Subdivisions or Partitions Phone: Contact name: Tricia Wolfe 503-730-9775 • Street widening • Mainline installation for Sanitary Contractor: Clog Busters LLC sewer, Storm sewer, Tigard water CCB#: A�, .��,� Expiration: j4-40-/q and/or Tigard Water Service Area Address: 2900 SW Cornelius Pass Rd#549 SUBMIT COMPLETED APPLICATION TO: City/state: Hillsboro,OR Zip: 97123 City of Tigard Phone: 503-680-8947 Email: tricia@clogbustersllc.com Planning/Engineering 13125 SW Hall Blvd. Contact name: Tricia Wolfe Phone: 503-730-9775 Tigard,OR 97223 Applications for"minor work in right-of-way" Engineer: only may be emailed to: rowpermitsna_,tigard-or.gov Address: City/state: Zip: Phone: Email: Case No.: F 1.T -LO if"d OO 67- Contact name: Application submittal fee(.07%of Engineer's Estimate) $ Estimated value of work is required(if over$5,000):$ Additional fees: $ „;?—A;Znr 010R, (within the public right-of-way) Application accepted: Is work related to a LAND-USE DECISION? ❑ Yes FZ1 No By: S(- Date: If so,please specify (MLP,SDR,SUB, etc.) case#: Appcati nli reviewed: By: Date: Is work related to a BUILDING PERMIT? ❑ Yes 0 No Applicant notified: If so,please specify(BUILDING PERMIT)case##: By: Date: I:\ENG\PermitApplications\pfi—application Effective 10/16/2017 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. * IXrith 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 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 propem. • 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. Patricia Wolfe 3/13/2018 Applicant/ thorize gent'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 North 9350 SW 70th ve,Tigard,ORi J S W 7 0 th I A v e i �I D 6 I Excavate in street 3'x10'x8' for sewer repair — — i VIC 43 Existing Sewer Line W ' 7�- Sewed Main �r 1 1 O ems-' `1 0 4—:7-N e' (yet � s� CCB Contractor Search http://search.ccb,state.or.us/search/business_details.aspx 8onstruction ontractors Board BUSINESS DETAIL Licensee : CLOG BUSTERS LLC Address : 2900 SW CORNELIUS PASS RD 549 HILLSBORO OR 97123 License No. : 200212 License Status: Active Date First Licensed : 6/18/2013 Expiration Date: 6/18/2019 Entity Type : Limited Liability Company Phone : (503) 680-8947 Endorsement Type : Residential General Contractor Workers' Compensation/Independent Contractor Status : Nonexempt ADDITIONAL BUSINESS LICENSES AND CERTIFICATIONS CERTIFIED LEAD-BASED PAINT RENOVATION (LBPR) CONTRACTOR LICENSE: NO Required to bid and work on pre-1978 residential structures. OTHER BUSINESS INFORMATION WORKERS' COMPENSATION INSURANCE INFORMATION Coverage Carrier Policy No. Employee SAIF 783662 Personal Election None None LIABILITY INSURANCE INFORMATION (History) Company Amount Effective Through 1 of 2 3/14/2018, 10:17 AM CCB Contractor Search http://search.ccb.state.or.us/search/business_details.aspx AMTRUST INTERNATIONAL j UNDERWRITERS DESIGNATED ACTIVITY $1,000,000.00 7/8/2018 COMPANY SURETY BOND INFORMATION (History) Type Company Amount Effective Through Residential WESTERN SURETY COMPANY $20,000.00 6/18/2019 Commercial None None None ASSOCIATED INDIVIDUALS Family Member WOLFE, PATRICIA DEANNE Family Member WOLFE, THOMAS JASON RMI Owner WOLFE, PATRICIA DEANNE Click 'i_: to see past associated individuals' names. ASSUMED BUSINESS NAMES(S) NAIL BUSTERS Click here to see past assumed business names. BACK BACK TO CCB HOME I BACK TO SEARCH ©2018 Oregon Construction Contractors Board 2 of 2 3/14/2018, 10:17 AM COVER SHEET Case # P FZ2,o[F`00� 2- Address: USO SV _�0'± A�g• PFI2018-00042, associated with 9350 SW 70th Ave, will be receiving revisions from ProFleet NW. Sam Copelan has already notified Al Dickman in Engineering that changes will occur. If any revisions appear in the ROW inbox, please notify Al Dickman. -Sam Copelan, Assistant Planner 2-28-2018 Th'(3 Ott,/ � sib � r J� POO dtsb. fluk 41/c� T�t_ 0cj (�L i r, -F-1 � �L20�g Woos � . C l t t' Aavc ae7 v SQ", la/-, 3- (1 --18