PFI2018-00222 UTY OF TMARD PUBLIC FACILITIES IMPROVEMENT PERMIT
e COMMUN TY DEVELOPMENT
Permit#: PF12018-00222
Date Issued: 09/04/2018
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421
Parcel: 2S111AC04600
Jurisdiction: Tigard
Site address: 14875 SW HEIDI CT
Subdivision: LAUNALYNDA PARK Lot: 14
Project: Teigen
Project Description: Pipe burst-replace concrete portion of sanitary sewer lateral from end of driveway in street to manhole
(approx. 40 feet)
Owner: FEES
Description Date Amount
PFI Permit Fee 09/04/2018 $300.00
PHONE:
Contractor:
BLACK ROCK UNDERGROUND LLC
267 NE 34TH PLACE
HILLSBORO, OR 97124
PHONE: 503-747-9312
FAX: 503-214-5886
Applicant:
DREW MCVEY
267 NE 34TH PLACE
HILLSBORO, OR 97124
PHONE: 503-747-9312
Total $300.00
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: V I T 0
i1
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12018-00222
Type: Condition Name: Status: Severity:
PFI—Sidewalk/1 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/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/[ 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 of Tigard AUG 2 7 2018
PUBLIC WORKS —FNGINIJIIRING
CITY OF TiGARD
PublicFacilityIreprovement (PFI) VP ff"NEERING
"fi '<��°•'.difilm'��"` nse :�N'd9,'$'.'�i"�T3._.wee_:,.uar`�5`w.a'k"w"'dp'�`.,' a5wY .;y u�x"��*.`s*'+..�`2s`dR�i ':'yv .fi54RVS`m.+t�*�"+FRrhi%�„�R�s?�&S�i3:���s:,.53�sao"'#F.L`.h�Y'�5
TYPE OF WORK
DESCRIP'T'ION OF WORK(in the right-of-way)
❑ TYPE 1— Fn.inchise. Unlit\-\York
(:heck otic: L tilItic5 p rforn-tcd by i \\�, P(J”
L+ � �tnct/or utility a�enc�.
Detailed description: ? J i `lAC.e. V% e
prkov, Oc.- �So% ` TYPE 2—Sidc���all:,/Drivcw:.ry�Sc���cr
a� Q � -� ow-, 2
�� ��� AVc1rk]��ertormed for the Purpose ot
rVN A � C'. :
SidC\\ail:installati"11 Or rLpair.
' ��` Q� � �� ��_�_ (� I�ri�-c\��at-apProacl].installatiotl
Propertyaddress/lucation(s)• { C� �J� and/c,r repit'
Sanitary sever lateral installation
and/or main Linc tap
❑ TYPE 3—1 ull scab Development
ilppl.icant:
\\ot:k Pcrf=armed with1.:anc] use
address: approval which inciudca XW t>f
CJty/sta.te: zIp: the.following:
Phone: I:':ma11: ° Subdivislotts or Nrtitions
° St:1'�rvl:�videnin
Contact name: Phone: °
Maintine instal_kition for Sanitary
1 t 1 sewer, Storm sewer, TiYard water
Contractor:�j�ow - vK- vAft C r100 L- L c ' .
and,,/or Tib and\ atel-SC1'\71CC .'\reg
CCI3#: � Expiration:
Address: qtp� H ier ^ SL'B�lI'I"COMPLETED APPLICATION I"Cl:
Cit../state:�I`1S�Do o z : �� ` 1�y City of Tigard
�je3,$�.�,�1�0 �o �p1 K LOQ Planning/Engineering
I hone.. I_;rnail: %4 @ 10l(, troy VYhA�t'�rOV' 13125 SW Hall Blvd.
Contact name:Dmw lvw4 av� P h o I I e S l-S•41ci0 Tigard,OR.97223
\}�plicarions kir niinor work in ri,,,,hr.-of-u:1�
rmla niav he cmailed if):
F;n,jneer: rowperinits Laj, and-ongov
Address:
e
(Jty/state: zip:
®,
Phone: F;maiJ: Case NO .: op
F
�,o17taCt name: /\pP]icarion SUI)ITtittal fee(.07'%,of
li,n�ir�eer's 1�,�,rit7�ate) ��•�
F,stirnated value of WO k is required (if over S5000):S Additional l=ees:
(within the public right-of-waN7) Application accepted:
Bv:
Is \,work related to a I..,AND-USL IDL"ICISJOND ❑ ❑ N
If so, please special- (MLP, SDR, SUIS, etc.) case # 1�pplicatit,n reviewed::: �a� B g
�B\1: 6 Date:
Is Urork related to a BLJILDITM'_� Pt'JUVIIT? ❑ Yes ❑ No Appticantnotified:
If so,please specify(BU ILDI.NG PLIU IIT)case#: 13 : {- Date;:
I:\ENG\PermitApplications\pfi_application Effective 10/16/2017
City of Tigard 13125 S\V (Tal_] t31vd. ° Bard,Ores ren c)1223 ° wwlv:Ci;ard-rar.;o�� ° .503-718-2421 ° Page 1 of 4
APPLICANTS
NOTE: Person spccificdas be designated '`Permittee"and shall provide financial assurance for�'vork, if
Z-1
required by ttic C1t\_PLA-SL1,11-It to TW] 17.041.140.
With rhc cxcepdon of-i urdiry opczmt1tl(r J_)LffsLMl1t to q valid fninchisc with dric Gh,oFTaIard..whcr, rhc owner and the applicant are different
people rhc apphcanr musr be rhe purcfia set-ot:record or"i I ""()n%v'rh wr' ar'on frorn dic owncr or an went of dic
cssee ill possession I irren aui-horiz i
OWTICI'. '1111C OWMT(S) 111LIS1, SiIi fl)ls apphci0(,)ii in the space:prf"vidcd or :l wriltCtl AL11[1101`i/Alloll With this application. 1�rtnchised
UtliltICS a1'C 110L ITTlil-Cd(1)f)IJ0111 the(mncr'.,sigmILLITC f.)1-1
BY SIGNING BELOW,THE APPLICANT(S) SMALLL CERTIFY T14AT:
•
The above:request docs not vl(,)Ittc-any recorded decd h.cstrictions ttiat rm.l.v be attacl-ted test or imposed tipurt the subject
• If the application is granted, the alDpllcaiat-w-111 exercise.the rights granted in accordance with the terms and subject to-ill the
C011ditioris and I I ill I t,_J r,I()IIS of t1le
• All of rliekovc steA.cmcrits,'Illd the st"Itcmcllt" in amr plot plata, exii1blis italismirted herewith,'21-C tt-Lic;RfId
they applicants So"1ck1-Lo\vlCdg(_' that ally'PCITI-Ilt ISSLIed, based on this application,ri-I-1-1v be revolved if It is found that ativ such
sta[cments ire False.
1111C 'eipplicAl I I _�
1-c- d the entire colUcrlts of fl-Ic apl)licatloii, ilicluding the policies and ctiterM,�trid Lmderstarids the
r( *-i -)plication.
rcquirc For�ff Aill,(,or dcnyti g tlic,-Il icatiori.
0 re'UJ MA, Q -7�Xlbl8
/�I-:)pfica ALithorized A0_ez S sic; tare Print name Date
SIGNATURES of each owner of the subject property, if required.
Owner's sig q121LL.IrC Print M.Mc Date
(._)Wrier's siopatLtrc Print thiffie Date
Owlier's SICY11RU11'e. Print tiariic Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City ofTigard J312,5SWHall I_3l-vd. - T'I(Ylll*d, ()i-c(,-(-,n9-12"-)3 503-718-24.211 - Page 2of4
Locate®noa Name: �°��� ��° Date: -7- t,2_-uos
,
RECEIVEPoint of Access: ®, xss cio
CITY OF TIGARD
Pt-� �NEERIN6Pipe Type: ', '��
NNIN�f�N g
Depth At Home:
Depth at Curb:
Depth At Main
Machine Access: 4V N
Dom - CIG�
oots 0 Pooling Of-Sets
0 Cracks
aA a
6 .� Repair T e mr�?\-)
Length of Repair: 401 A,
Mese �ac.-cA-r-,a, o^
C_01 -- - Sr,&
l
I-�e\o�;;, C�.
0 P4--
Rc�o�
RECEIVED
toot`
AUG 2 7 2018
CITY OF 7lGAAD
,N �A�"' PLANNING/ENGINEERING
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> O IA Sw ae:d, CA
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