PFI2018-00260 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12018-00260
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 09/25/2018
Parcel: SEG1931
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Jack Howk Plumbing/Rescue Rooter
Project Description: Adjacent to 8935 SW Pinebrook St.Approximately 10-foot sewer replacement in ROW planter strip.
Owner: FEES
Description Date Amount
PFI Permit Fee 09/25/2018 $300.00
PHONE:
Contractor:
JACK HOWK PLUMBING/RESCUE ROOTER
PO BOX 2830
CLACKAMAS, OR 97015
PHONE: 503-850-3100
FAX: 503-491-2932
Applicant:
JOYCE DENNIS
PO BOX 2830
CLACKAMAS, OR 97015
PHONE: 503-850-3100
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 PF12018-00260
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/[ 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.
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.
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/1 09-OTHER Applied Notice
RE
City of Tigard SEP 2 4 2018 / y
PUBLIC WORKS — I.-MINEERINt OTY OF TiGARD
PLAPublic FadhtyImproveNING/ENGINEERIment`� (PFI) Permit
oft Now
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-,way)
❑ TYPE I-Franchise Utility Work
Check one: ❑ Zltilitit:s ElSk1v�,alk/c dv,,%%at apprulcl ❑5 cetin'►prnt•ct -n pertorrncd byNXVN, PGH
e
L� and/or utility wric}•.
Dsled d
ll XTYPE 2—Sidcu�all;/Drit-c%�^a}•/5c.4•cr
Work p crformcd for the purpose of:
--- • Side«?:►lk installation or repair.
• Dn'VC%%•a)•approach instxllatio►►
Property a r lv aticn(s): / and/or rerair
0AISanitan-sewer lateral installation
and/or main line tap
�r���.
1:1 TYPE 3-Pull scale Development
�j''�r//����/ Work-performed with Land use
Address- approval which includes ant-of
Cit ,/state: Zip: the fullowing:
P Email:
� e Subdivisions or Partitions
AFEAMEAR
Strect widening
Contact name, I hone:
i251j) • Mainline installation for Sanitary
,9Contractor: i/ sewer, Storm sewer,Tigard water
and/or'rigard Water Service Area
C:C:B#: Espiratio
Address: 10ANneW�09SU BM rr COMPLETED APPU CATI ON TO:
City/state: Zip: City of Tigard
Planning/Engineering
Phone: Email: 13125 SW Mall Blvd.
Contact name: Phonc: Tigard,OR 97223
:applications for"miner work in right-of-way"
I•:nginecr:
only ma}•be emailed to:
rowpemnits gtiga� rd-or.gov
Address:
C:it%�/state: Zip:
Phonc: Email: Casc No.:
Contact name: tlpphcation submittal fee(.071%,of
l:ribincer's Estimate) 5
Estimated 1-alue of work is rquired(if over S5,000):S � Additional fees:5 23 C76
(%xithin the public right-of-way) Application cceptcd: 9�?qj Is work related to a IAND-USI^ DE-.C:ISI()N? ❑ Yes �No
If so,please specify(NMIT,SDR,SUIS,etc.) case #: :Lppticaoon reviewed:
Bt•• U Date:
Is work related to a BUILDING PERN'iIT? X Ycs Applicant notified.
12s;-1I
t so leases specify(BUILDING PFRI1•II case#: � B>•: 1°� Date: l
P P . {P T)
-Ntnc\PermilAP3k4+;ons%p"ooWAtion DlK we 10/16/7017
City of Tigard 13125 Sit'Hall Blvd. • Tigard,Oregon 97223 • wwu.tigard-or.gov • 503.718 2421 - Page 1 of 4
APPLICANTS
NOTE: Vcrsoa specified as "Applicant"shall be desl.gmatcd "Krmittee" and shall provide Financial assurance fur wiwk,if
required by the c1tV pursuant to TL%[(. 15.04 1.14(.-).
1\i h the exception )f:1 k6lit% oper-6ng purs"I 1-1,["-.1 forichi5c vizil the Cizzy o"'Figard,when the()wner and the ipplicant ar.,differc-n-
people,Elic applicaric m1w be the purchaser of rxnrd or a 1,i�cc in «i-it xrUrcti alithon'/,vion ftom Ohm owtwr t,r an ageni cj,7 dht
I Tb, ')i -t z'�Llll ,h i 1 1.CA 60 Ll i'l t Z S V 1 rOVi I 14!d Fir,uhm i a m-ri z z c i i i Eli o 6/a-i)!1%7,'L:I i t I i i s -i p plicat i i. Fra ti c i i i�t,i
.,a n-r. -n,,i I I
Urili[i:s arc moz roquircil it,cb-..iir.the owner'F$1,1,111.1tArr.W,the application
BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT:
- mic above r4qs,cs,1 does not violate any recorded decd resuictions that ma% he attached to or injUQSCd Upon the SL1bi(!Ct
propertv.
- If the application is granted,theapplicant will c\erci,;.-,the right.;granted inaccord-ance'with the terms and<ublcct to'III the
cotlditicms and limicatiom;of the approval.
- All of tile abovc statements and the statements in in%-plot plan,attachments,and exhibit.,transmitted herewith,are LrLIC;and
the applicants so acknom-ledge that any permit issued,based on this application,may be revoked if it is found that any such
st'.1letllc(lts Ire fake.
- The applicant has read the c contents of the appEcation,including the policies and criteria,and understands the
re(JUiremcnis for approxi ,or denving the application.
o� Dag
Applicant/Authonized Agent's signimUre Print naml Date
r*1 0
SIGNATURES of each owner of the subject property, if required.
Owner's sio4nnatUtC Print name Date
Ommer's signature Print name Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City qfTigard - I3I25S\VHall BI%-d. - Tigard,Oregon 9-223 - wwwdgard-or.goi. 503 '718-2421 - Page 2of4
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SKETCH AREA:
DATE:
PROJECT ADDRESS:
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PROVIDED BY: ARS dba Jack Howk/Rescue Rooter-, P.O. BOX 7$301
Clackamas, OR 07015, Prone: 503-850-3100 Fax. 503-491.-2932)
SKETCH AREA:
DATE: X19 Y//�l
PROJECT ADDRESS.
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PROVIDED BY: ARS dba .lack Howk/Rescue Router, P.O. BOX
Clackamas, OR 07015, Phone: 503-850-3100 Fax: 503-491.2, �