PFI2018-00248 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12018-00248
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 09/20/2018
Parcel: 2S111CD01200
Jurisdiction: Tigard
Site address: 9500 SW SUMMERFIELD DR
Subdivision: SUMMERFIELD NO.7 Lot: 362
Project: Miller Sidewalk Repair
Project Description: Adjacent to 9500 SW Summerfield Drive. Repair sidewalk.
Owner: FEES
Description Date Amount
PFI Permit Fee 09/20/2018 $300.00
PHONE:
Contractor:
FOREST LANDSCAPE INC
3975 NW SUSBAUER RD
CORNELIUS, OR 97113
PHONE: 503-648-8308
FAX 503-648-8095
Applicant:
JOANNA CASTANEDA
3975 NW SUSBAUER RD
CORNELIUS, OR 97113
PHONE: 503-648-8308
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:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12018-00248
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/[ 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/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/[ 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 SEP 17 2018
� I'i }iI.I(: 1t,r)Itl�S 1•,1�(,I�I•.I•.kl'�(� ,.,.._
u{I�'Y OF TIGARD
e Fadity Improvement
`'ENGINEERINGPubfic (PFI)
TYPE OF WORK
DESCRIPTION 01:WORK(in the right-of-way)
❑ TYPE 1–I'renc hist I'ulnr tC nr{;
Check talc•: (1 1,1111tic., \1 S11lcwalk/dri%cwa\ app mach 115trcctimp t,wrm(nts lx.rf►►mucl b) N\t'�. 1411;
anti/or utillh af(nt;.
Detailed description:
cC 1 ��� \7E 2–Sidctc•alk 11)ri�(-wa)/Scv•cr
�!Sl ;
pe
rf�irmrd for the rurlx,qc r►f:
• Siclru•alk installation or repair.
• Driveway approach installatint,
Prc�perh address/locaticn(s): �� �, „�,� ,,�r��Y�1 e and/or repair
• Sanitar<•sewer lateral instillation
anti/or main line tap
Applicant: Ln ,6,<� , 1 ��C C1 TYPE 3–pull scale Dec•elopment
—� , Work performed with 1.2nd use
Address: j 1`��,�) 3L:/�� 0 )P Y approval which includes any of
City/state: r .11 k L�� ` 9 zip: i the f Illo%vinK.
Phone: E.rnail: nnn•E�rey{/o� tcL<za Pein ,CD • Suhdivisions or Partitions
Contact name:�(70.Y\hG Phone: • Street andcnin�
• ;Mainline installation for Sanitan-
Contractor.
�'`• sewn,Sturm sewer, Tigard water
� and/or Tigard Water Service Area
CCB#: . 1 5:L� Z Expiration:
Address:.��IS SV to� al' �e r SUBMIT COMPLETED APPLICATION TO:
Cin,/state:CDC'Yxk_Ai V j OR Zip: 7 1 �,� City of Tigard
Phone:5o'SCPlasning/Enainetring
nyRR��t?mai)Jam► �r �la�ytcelb�lOh� 13125 SW Hall Blvd.
Contact name:, lnrn Phone: Tigard,OR 97223
Applications for"minor work in right-of-aay"
Engineer: only mal.he emailed to:
permiitsrfi ard-or.gov
Address:
City/state: Zip:
nmi
Phone: Email: ease tics.:����g'OL)2,L"e
Contact name: application submittal fee(.07%of
F.riginrer's 1?stimate) $
Estimated value of work is required(if overS5,(XX)):$ Additional fees:S 300
(xrithin the public night-of-way) Application accepted:
� 11
Is-work related to a LAND-USI:DFICJSION% ❑ Yes �No Iit•• Date:
lie,
If so,please specift(MLP,SDR,SUB,etc.)cast #: Application rcVieWu1:
- Bl.: I)atc• 1 J
1s work related to a BUILDING PF,RNIIT? 0 Yes t9\No Applicant notified:
If soy,please specifi•(BUILDING PERMIT)case#: B}•: Date:
1:\ENG\perm tApphcations\pfi application Eftcnwo 10/16/2017
Cin•of Tigard 13125 MV(!all Md. • 'l'igard,Oregon 97223 w-,%r\%:tigard-or.go\- • 503718-2421 Page 1 of 4
APPLICANTS
NOTE: I vrso►n spcctiicd a,,".111plioltil' shall Ix designated'Tcrmim-c"mu shall prt,t,idr financial,t�%rJncc f6r ut,rl:,tf
rcquircd be the cttN-pursuant 15,1141.140
1C rill the cr,ception of a uultt\operatutt;purmmant to a%,Ad IranuIim with the t.ttt of Tt:r,rtl,u h n the r,u nor:inrl rbc app tc.inr an ditto rc rit
pcv,ple,the applh ant nnnt Ix the pi urt 1wvr of rcmrcl or a rn kion with .+rittcn iiit'v,n.atu,-i front the tm ricr or;n aj�:cnt of t ,-
nun+Y 'll+c-m-ncr(sl must sihn tlhi":q,plic.tti1m in tlhc%pace litmitictl-,r sul,mit:i urmn rrton with t-vi,;.t;,hhc.itinn. i ranch,,(d
nhno arc ma required to oboin the ou•ncr s signaturc on the apph(atinn
BYSIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT:
• 111e aburc request docs not violate an),retarded decd restrictions that mai•be attached to or imposed upon the subject
rot •r .
• If the application is granted,the applicant will exercise the rights granted in accordance with the terms and suhjcct to all the
conditions and limitations of the approval.
• All of the above statements and the statements Many 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 I5 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
requirement,,for approning or doming the application.
L Y--Ana Ch-A- 2- q 11L)
i2a
11r ant :lutO zed AgLoies signature Print name Date
SIGNATURES of each owner of the subject property,if required.
Owner's signature: Print name Date
0v,ner's signature Print name Date
()u ncr's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
Cin of Tigard i?125 SW Hall lii,d. • Tir1ard,Oregon 97223 - Nt a-%v.6gard ()ngov 503 718-2.121 Page 2 of 4
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