PFI2018-00180 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12018-00180
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 07/16/2018
Parcel: 2S114BA10800
Jurisdiction: Tigard
Site address: 16450 SW MEADOWOOD WAY
Subdivision: COPPER CREEK STAGE 2 Lot: 61
. Project: Nyquist Sidewalk repair
Project Description: Adjacent to 16450 SW Meadowood Way. Repair 5'x 15'sidewalk.
Owner: FEES
Description Date Amount
PHONE:
Contractor:
CONCRETE CONSTRUCTION CO INC
18205 S GRASLE RD
OREGON CITY, OR 97045
PHONE: 503-631-4482
FAX:
Applicant:
GEORGE VERSCHINGEL
18205 S GRASLE RD
OREGON CITY, OR 97045
PHONE: 503-631-4482
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 (} ^I
Signature:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12018-00180
Type: Condition Name: Status: Severi :
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.
PF1_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/1 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/1 09-OTHER Applied Notice
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q �a PUBLIC WORKS — ENGINEERING
CITY OF TIGARD
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NEEiNGCPublic FacilityImprovement (PLTITYPEtmit
TYPE OR WORK
DESCRIPTION OF WORD(in the right-of-way)
❑ ']CYI'E 1—Franchise Utility Work
Check one: ❑ Utilities DeSidewalk/!j i�eway approach ❑ Street improvements performed by NWN, PGE and/or utility agency.
Detailed description: �� ��S �� '� 'i9�=:�,,�C, �'�- i,V" WTYPE
2—iSidewalk/Driveway/Sewer.
Work performed for the purpose of-
- Sidewalk installation or repair.
® a Driveway approach installation
Property address/location(s): , fn and/or repair
Sanitary sewer lateral installation
and/or main line tap
`"�' ❑
TYPE 3—Full scale Development
Applicant: �nccoc , Work performed with Land use
Address: 1g-2D5-& _� 6jaka approval which includes any of
City/state: n(r_w-3N. W, (f)f Zip: I the following:
Phone:` , _ mail: (D L+t 1710, ° Subdivisions or Partitions
Contact name: d', i Phone: Street widening
° Mainline installation for Sanitary
a - sewer, Storm sewer, Tigard water
Contractor: V
and/or Tigard Water Service Area
CCB#: ( r Expiration: -si tc,
Address: V g `J�t % ,� ` SUBMIT COMPLETED APPLICATION TO:
City/state: v( Zip: City of Tigard
Planning/Engineering
Phone: �' ` mail: - y 13125 SW Hall)Blvd.
�nd Tigard,OR 97223
Contact name: Phone: g >
Applications for"minor work in right-of-way"
only may be emailed to:
Engineer: rowpermitsnae,tigard-or.gov
Address:
umm ziw un ONIV
City/state: Zip:
Phone: Email: Case No.:
Contact name: Application submittal fee (.007%of
Engineer's Estimate) $ '
J
Estimated value of work is required(if over$5,000):$ J _ Additional fees: $
(within the public right-of-way) Application accepted:
Is work relate to a LAND-USE DECISION? Yes No By: Date:� I..
d ❑
If so,please specify (MLP,SDR, SUB, etc.) case #: .Application reviewed:
By:-lv� 0- Date: 7/1(o /(2:)
Is work related to a BUILDING PERMIT? ❑ Yes D�No Applicant notified:
If so,please specify(BUILDING PERMIT)case#: By: Dater 11 __
I:\ENG\PermitApplications\pfi—application Rev.10/16/2017
City ofTigard ° 13125 SW Hall Blvd. ° Tigard,Oregon 97223 www.tigard-or.gov 503-71$-2421 Page 1 of4
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APPLICAN'T'S
NO'M'E: 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 Cite 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 APPLICANTS) SHALL CERTIFY THAT:
• The above request does not violate ani,recorded deed restrictions that may be attached to or imposed upon the sub)ect
proper .
• If the application is granted,the applicant gill exercise the rights granted in accordance with the terms and sub)ect 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.
0A> "A
Applica u orized Agen s ignature Print n e U 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 ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 2 of4
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DEVELOPMENT ENGINEERING FEES
FOR STAFF USE ONLY
Public Facility Improvement(PFI)Permit:
DETAILED SUBMITTAL
REQUIREMENTS
APPLICATION FEE
Part 1: Required submittal fee$300.00 (minimum) FRANCHISE UTILITY AND SIDEWALK/
DRIVEWAY AND UTILITY
PERMIT FEE CONNECTIONS,.ETC.
Part 2: All non-water system improvements (work in the right of way)
Engineer's estimate X 5% (less$300.00 minimum
submittal fee) Sketch
Engineer's estimate X 2%Plan Review (including information below)
El Dimensions
WATER SYSTEM FEE El Street Name.
Part 3: All public water system improvements ❑ Site Address
Engineer's estimate X 12%
FULL SCALE.DEVELOPMENT
PFI Permit Fee Exemptions: (Subdivisions/Partitions and Street Improvements)
There will be no permit fee charged,or assurance required
for the following types of work: Design.plans
• Sidewalk repair(less than 20 lineal feet) (6 sets;24x36 or 22x34)
• Relocate or replace mailbox ❑ Cover—Site,'Vicinity;Abbreviation,Legend
• Ditch cleaning that does not involve regrading. GeneraIN afes-(City,Water,Sewer,etc.)
• Weep hole repair ❑ Street(Plan,Profile)
• Curb repair or replacement(less than 20 lineal feet) ❑ Water,Storm and Sanitary(Plan Profile)-
• Lawn sprinkler system installation or repair [�j Water Quality Facilities
• Street tree pruning or planting ❑ Grading
• Planter strip landscape maintenance ❑ Landscaping%Tree Plan_
• Test wells ❑ Composite Utility Plan(Electrical,Phone,Gas,
Storm;Sanitary;Water,Signage,Street Lights etc)
❑ Details
Note: A cash/bond assurance maybe ❑ Traffic Sight Distance
required per TMC 15.04.140. ❑ Signing.and Striping
(customer deposit) ❑ 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)
0 Water Department Approval
El Engineers Construction Estimate
PUBLIC FACILITY IMPROVEMENT PERMIT
City ofTigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 0 www.tigard-or.gov 503-718-2421 • Page 3 of4
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SAMPLE SKETCH:
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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 ofTigard a 13125 SW Hall Blvd. a Tigard,Oregon 97223 a www.tigard-or.gov • 503-718-2421 • Page 4 of4