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Clean Water Services File Number
CleanWate� Services 18-002086
Sensitive Area Pre-Screening Site Assessment =W�
1. Jurisdiction:Waahingten-qty TIGARD , L![ ?Ala
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2. Property Information(example 1S234AB01400) 3. Owner Information CITY I k 2 °�a°
Tax lot ID(s): Property ID W263591 Name:GREG&MELISSA FOL Y ALO jtM.
State ID IS 136CA01200 Company: kQ) µ
Address: 11280 SW 78TH AVE.,
Site Address: 11280 SW 78TH AVE., City,State,Zip:TIGARD OR 97223
City,State,Zip:TIGARD OR 97223 Phone/Fax:
Nearest Cross Street: E-Mail:
4. Development Activity(check all that apply) 5. Applicant Information
Addition to Single Family Residence(rooms,deck,garage) Name:MIKE MONTGOMERY
❑ Lot Line Adjustment ❑ Minor Land Partition Company:SIMPL HOME DESIGNS
❑ Residential Condominium ❑ Commercial Condominium Address:4931 SW 76TH AVE., PMB 211
❑ Residential Subdivision ❑ Commercial Subdivision PORTLAND OR 97225
C:1 Single Lot Commercial (:) Multi Lot Commercial City,State,Zip:
Other NEW GARAGE AND SECODN FLOOR ADDTIOQ Phone/Fax:503-515-6495 O/503-7194825 F
E-Mail:mikem@ezpermits.biz
6. Will the project involve any off-site work? ❑Yes la No ❑Unknown
Location and description of off-site work
7. Additional comments or information that may be needed to understand your project
This application does NOT replace Grading and Erosion Control Permits,Connection Permits,Building Permits,Site Development Permits,DEQ
1200-C Permit or other permits as issued by the Department of Environmental Quality,Department of State Lands andlor Department of the Army
COE. All required permits and approvals must be obtained and completed under applicable local,state,and federal law.
By signing this form,the Owner or Owner's authorized agent or representative,acknowledges and agrees that employees of Clean Water Services have authority
to enter the project site at all reasonable times for the purpose of inspecting project site conditions and gathering information related to the project site. I certify
that I am familiar with the i ation contained in this document,and to the best of my knowledge and belief,this information is true,complete,and accurate.
printay, `ike'%ntgome Print/Type Title Agent for owner
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Signature `ii< TalillDate Jul 8,2018
FOR DISTRICT USE 0 Y
❑ Sensitive areas potentially exist on site or within 200'of the site. THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO ISSUANCE OF A
SERVICE PROVIDER LETTER. If Sensitive Areas exist on the site or within 200 feet on adjacent properties,a Natural Resources Assessment Report
ay also be required.
Based on review of the submitted materials and best available information Sensitive areas do not appear to exist on site or within 200'of the site.This
Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect water quality sensitive areas if they are subsequently
discovered.This document will serve as your Service Provider letter as required by Resolution and Order 07-20, Section 3.02.1. All required permits and
approvals must be obtained and completed under applicable local,State,and federal law.
Based on review of the submitted materials and best available information the above referenced project will not significantly impact the existing or potentially
sensitive area(s)found near the site.This Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect additional water
quality sensitive areas if they are subsequently discovered.This document will serve as your Service Provider letter as required by Resolution and Order
07-20,Section 3.02.1. All required permits and approvals must be obtained and completed under applicable local,state and federal law.
❑This Service Provider Letter is not valid unless CWS approved site plan(s)are attached.
❑The proposed activity does not meet the definition of development or the lot was platted after 9/9/95 ORS 92.040(2). NO SITE ASSESSMENT OR
SERVICE PROVIDER TTER IS REED.
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Reviewed by ...r
Date 07/09/18
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DRIVEWAY&SIDEWALK 401e SQ FT
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LOT COVERAGE: III
LOT AREA 10.047'SQ FT '
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BUILDING AREA I.862'SQ FT q.1 q:1
PORCH 60'SQ FT
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BUILDING%COVERAGE IS 0.180R 18%
Address 11280 SW 78TH AVE.,TIGARD OR
Property ID W263591
County Washiagtoo
4 State ID IS136CA01200
Alt Account Number R2S2394
Land Type SFR
Total Land Area 10,047
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