PFI2018-00110 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12018-00110
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 05/11/2018
Parcel: SEG329
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Sidewalk Repair Ashwood Ct
Project Description: Water service replacing, replacing side walk panel
Owner: FEES
Description Date Amount
PHONE.-
Contractor:
HONE:Contractor:
PHONE:
FAX:
Applicant:
RAELYNN ERHARDT
524 N TILLAMOOK ST#102
PORTLAND, OR 97227
PHONE: 503-680-4428
Total $0.00
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 PF12018-00110
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/[ 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. Call Jonny Gish 971-713-0281 or Jonny@tigard-or.gov
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 o.f Tigard MAY 10 201$
CITY OF OF TIGARD-
�
PUBLIC \Y()RISS — I,.\,t .Ll✓RI'_�CJ PLANNING/ENGINEERING
Public Facilit-. Improvement (PFI) Permit
TYPE OF WORK
DESCRIPTION OF WORE,(in the rigl,. '..way)
❑ TYPE 1-Franchise Utility\t'urk
Check one: ElUtilities Aidcwak/drvcw i.� ;i L]Street improvements performed by PGE
� � l and/or utility agenct•.
Detailed description V C y"uhc-e R-�
TYPE 2-Sidewalk/Drivewat/Sewer
Work performed for the purpose of:
llf—
• Sidewalk installation or repair.
> • Driveway approach installation
Proper"- address/location(s): �� LT and,'or repair
_ 2,3r 2 Sanitar, sewer lateral installation
�d
and/or main line tap
i ❑ TYPE 3-bull scale Development
Applicant. r1�?�1�k5 W U✓�u11 `L Work performed with Land use
Address: C� Iy (Z approval which includes any of
Cite'/state: rel-rfWA OR• _ Zip: the following:
PCt� Subdivisions or Partitions
-�• 3 �• _���'S ���.�_K� l ,mow.
Contact name: Ij11►1 Yt�tr�/Dlf i ne:
_S�.S' • Street widening
• :Mainline installation for Sanitary
sewer, Storm sewer, Tigard water
Contractor: 5 G DVS and/or Tigard\\Fater Service Area
CCB#: fb�`j`��`r _ 1;_. ition: y Y 0 6 -X;LL)
i
Address: r nL-� SUBMIT COMPLETED APPLICATION TO:
Citi'/state: _ Zip: City of Tigard
Planning/Engineering
Phone: I;trail: 13125 SW Hall Blvd.
Contact name: 4: ' Tigard,OR 97223
Applications for"minor work-in right-of-way"
Engineer: __ _
mmly may be emailed to:
rovN32ermitsCati„ard-or.g�v_
Address:
Cite/state: Z_ip:
Phone: Email: _ Case No.: & 0110
Contact name: _- Application submittal fee(.07°o of
- Engineer's Estimate) $
Estimated value of work is required(if c N,cr 100):� Additionai fees:
(within the public right-of-v-:t\; Application accepted: r')
S I v
Is work related to a LAND-USE DECISI( p Yes XNu By: M a Dare:
If so,please specify (INILP,SDR,SUB,etc.) Application rerie«�ed:
e#:
By-J �— Date:
Is work related to a BUILDIXG PERNll'l--. Yes W No Applicant notified:
If so,please specifj-(BUILDING PER`IIT' e#: IF- By: -Date:-g--1iih6
i:\EKIG\Perm.Uppiications\pfi_appikation Effective 10/16/2017
City of Tigard 13125 S\\•1,all PA-d. d,Oregon 97223 • vr\vw igard-ongov • 503-718-2421 • Page 1 of 4
APPLICANTS
NOTE: Person specified as".-applicant"sl, )e designated "Permittee"and shall provide financial assurance for work,it
required by the city pursuant to TMC 15.0.1 W.
" With the exception of a utility operating pursuant; �-alid franchise with the Cit)of Tgrird,when the owner and the applicant are different
people,the applicant must be the purchaser of rcc(: --a lessee in possession with written authorization from the owner or an agent of the
owner. The owners)must sign this application it space provided or submit a written authorization with this application. Franchised
Utilities are not required to obtain the o\vner'>sign on the application
BY SIGNING BELOW,THE APPLIC-t`: '(S) SHALL CERTIFY THAT:
• The above request does not violate any recon feed restrictions that may be attached to or imn�,sed upon the subject
ro er
• 1f the application is granted,the applicant«vi' _rcise the rights granted in accordance with the tc rms and subject to all the
conditions and limitations of to.:approN.u.
• All of the above statements and the statcmea;, i any plot plan,attachments,and exhibits transmitted herewith,are true;and
the applicants so acknowledge that any perm -ued,based on this application,may be revoked if it is found that any such
statements are false.
• The applicant has read the enure contents of ,application,including;the policies and criteria,and understands the
requirements for a roving;o denying;the�c; ttion.
I
1pplic nt/Aut prized Agent's signatu.e Print nam Date
SIGNATURES of each oxvner of the sv -t property, if required.
Owner's signature Print name Date
Owner's signature Print name Date
Owner's signaturc Print name Date
PUBLIC CILITY IMPROVEMENT PERMIT
City-of Tigard • 13125 Saa-l lall Blvd. • ' rd,Oregon 97223 • -%v\vwtignrd-or.gov 503-718-2421 • Page 2 of 4
RESIDENTIK AS BUILT DRAWING
Site Address Permit Number
1
444�!
r
Contractor: 3 &&ptLfa4-kL!j . 0071 1 '&b. ' &-'Ve4L L,L L- CCB:
Address: Date:
City State,ZIP: i� G _ ��"7 RS_Sewer-As_Buift 07/17/17
DEVELOPMENT ENGINEERINt: `EES FOR STAFF USE ONLY
Public Facility Improvement(PFI)Permit: DETAILED SUBMITTAL
APPLICATION FEE REQUIREMENTS
Part 1: Required submittal fee S300.00
FRANCHISE UTILITY AND SIDEWALK/
PERMIT FEE DRINrEWAY AND UTILITY
"(' ' N ECTIONS,ETC.
Part 2: All non-water system improvement,
r' rk ;i-,,c right of way)
Engineer's estimate K 5%(less 5300.00 subr. -►1 fee)
Engineer's estimate K 2%Plan Review Sketch
Jr,- .ding inr'ormarion below)
WATER SYSTEM FEE mr,.Fr y•{
rers
Part 3: All public cater system improvt-in, trecr dame
Engineer's estimate X 12"/to Vsitc Address
PFI Permit Fee Exemptions: FULL SCALE DEVELOPMENT
There will be no permit fee charged,or assn: -required
'Subuirisiunsi Partitions and Street Improvements)
for the following types of work:
• Sidewalk repair(less than 20 lineal feet)
• Relocate or replace mailbox (6
Plans
• Ditch cleaning that does not involve regr (6 sets,24x36 or 22x34)
,.
• Veep hole repair Q Cover—Site,Vicinity,Abbre-, ation,Legend
• Curb repair or replacement(less than 2011. 1 feet) :1 General Notes(Cit},Water,Sewer,etc.)
• Lawn sprinkler system installation or repo: ❑ Street(Plan,Profile)
• Street tree pruning or planting ❑ 'Vater,Storm and Sanitary(Plan Profile)
ED• Planter strip landscape maintenance a Quality f=acilities
• 'fest 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) F-1 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 l'se conditions)
L, rr8riic Report
❑ storm water Drainage Calculations
❑ Geotechnical Report
❑ Preliminary Access Report(Sight Distance)
❑ Proposed Plat
❑ Pathway Design(if applicable)
❑ Water Department Approval
D Engineers Construction Estimate
PUBLIC - ,CILITY IMPROVEMENT PERMIT
City of Tigard 13125 SWI-lall Blvd. • rd,Oregon 97223 • u•v,-v.,tigard-or.gov • 503-718-2421 • Page 3 of 4
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