PFI2018-00170 CITY OF TIGAR® PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PFI2018-00170
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 07/10/2018
Parcel: 2S102AD01203
Jurisdiction: Tigard
Site address: 8800 SW COMMERCIAL ST
Subdivision: None Lot: None
Project: Magno, LLC
Project Description: Replace 50 square feet of sidewalk.
Owner: FEES
Description Date Amount
PHONE:
Contractor:
JAY JACOB MILLER
8152 SW HALL BLVD#240
BEAVERTON, OR 97008
PHONE: 503-707-4725
FAX:
Applicant:
JAY MILLER
8452 SW HALL BLVD#240
BEAVERTON, OR 97008
PHONE: 503-707-4725
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 PF12018-00170
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/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/1 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/1 09-OTHER Applied Notice
RECEP,VIED
x-
City of Tigard J U L 0 5 2018
PUBLIC WORKS — ENGINEERING CIT`r OF T?CAF1D
Facihty Improvement �TMT
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
❑ TYPE 1—Franchise L`rilin \Fork
Check one: ❑ Utilities C,%,SA etivalk d6ve%va\'approach ❑ Streetim roeeinents performed by N\\!-N PGE
...! and/or utilin�agency.
Detailed description:
TYPE 2–Sidewalk/Drivewav/Sem er
A"Ork performed for the purpose ref:
• Sidewalk-installation or repair.
• Drivewayapproach installation
Property= address/locatiorl(s): and/or repair
• Sanitan'sewer lateral installation
and/or nialIl line tap
❑ TYPE 3—Fa scale Development
Applicant: \Vork performed with Land use
Address: Ai approval«lzicli illcludes any of
Cit-v/state: Gip: the folloxving:
Phone: E-mail: • Subdivisions or Partitio m
• Street xideni.ng
Contact name: Phone:
Mainline installation for Sarntary
sexve.r, Swim sewer, Tigard water
Contractor. ; Mj vvv�r 1-�;
and/or Tigard\\%ater Service,.gest
CCB#: Elpira on:
Address: p741() SLTBMIT COMPLETED APPLICATION TO:
Cite/state: [X/wYi' Gip: City of Tigard
e- `' F�mail: � ! � PlartninglEngrneering
Phon
``�`��� 13125 SW HaH Blvd.
Contact name: 1)11oIIe: 2?!72 41 Tigard,OR 9722.3
Applications for"aiitux xvork in n ht-cif-anti°„
�nr121e(I: only mai be emailed to:
row-permits(a�i Bard-or.gov
Address:
Cite/state: Zip: _
Phone: Email: Case No.: rl ;2015 X/-76
Contact name: Application subr uttal fee(,07%of
Engineer's Estimate)
Estimated value of work is required(if over S5,000): :additional fees:
(v6thin the public right-of--,vay) Application accepted:
Bt•: Le 2 Date:
Is work related to a LAND-USE DECISION? ❑ Yes �No
If so please specify-(MLP. SDR,SUB,etc.) case #: Application reviea.ed:gj G� g
Bv: Date /
Is work related to a BUILDING PEILMIV ❑ Yes \42T No Applicant notified:
If so,please specify(BUILDING PERMFII case#: B\1: � Date:
I:\ENG\Pet mitFppGcations\pfi appkication Effective 10/16/2017
City of Tigard • 13127 S\t-l-call Blvd. • Tigard,Oregon 97223 wwwtigard-or.gov a 503-718-2421 11 Page 1 of 4
APPLICANTS
NOTE: Person specified as"Applicant-shall be designated "Permittee"and shall protide financial assurance for work,if
required by the cit},pursuant to TIN'IC: 15.04.1.140.
\Vith the exception of'a pr)rsuant to a valid franchise with the CM.of'l'i�mrd..when the oxvner nd the Applicant arty different
people.the applicant rnust be the purchaser of record or a le�sec in poi se sion with written authorization from the o\vncr or an agent of the
r 'l e cnmtmust sitn this application in the space prof*icied or submit a written authorization with this application. Franchised
utilitie are not rcquirrd to obtain the owwr's silntature oft the application
BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT:
• The abo-ve request does not violate atm recorded deed restrictions that may be attached to or imposed upon the subject
ro ert-,
• If the application is granted,the applicant will exercise the rights granted tri accordance\with the terms and subject to all the
conditions and llinitatlons of the approval.
• All of the above statements and the statements in any plot plan,attachments,and exhibits transmitted herelz-ith,are true;and
the applicants so acknowledge that ane permit issued,based on this application,mat-be revoked if it is found that ane such
statements are false.
• 'l1ue applicant has read the entire contents of the application,including the policies and criteria,and understands the
requirements for approl-ing or denying the application.
:app 'c n z 's „signature Plat na -lc Date
SIGNA'T'URES of each owner of the subject property,if required.
04, 06
Owner's signature Print name ate
Owner's signature Print name Date
Owner's signature Print name Date
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PUBLIC FACILITY IMPROVEMENT PERMIT
Cita=of Tigard 13123 S\�`Hall Blvd. • I:igard,Oregon 97223 «-wwtigard-ongov 503-718-2421 • Page 2 of 4
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CCB#
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CCB# 198613 DC 7 0
Eliminate Trip Hazards
i F
Property owners are responsible For the repair and maintenance of the sid ewe Iksadjacent to their property.Avoid the costs,dangers
and hassles of being involved in a trip hazard lawsuit for personal injury.Your neighbors, children on bicycles or skateboards, new
no
mothers with baby carriages,disabled people in wheelchairs and everyone else have one common need:A smooth,safe sidewalk.
Let our experienced proFessionaLs grind out trip hazards or replace sidewalk sections as needed. '
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Subtotals
Areas: Est.L. Ft.:
Other:, V,0, kvvoo� GR P""wT
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1(2)Sidewalk Replacement
Areas: Est.L. Ft.: j d Est.Sq. Ft.:50
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Bill
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Sidewalk Replacement
Warranty
Disclaimer
Acceptance of Proposal
71
Buyer Signature- Date:
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Contractor Signature: -e:
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