PFI2018-00267 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12018-00267
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 10/02/2018
Parcel: 2S 103AC05000
Jurisdiction: Tigard
Site address: 12797 SW 113TH PL
Subdivision: HUMBOLDT CREEK ESTATES Lot: 1
Project: Tinsen
Project Description: Install new 20'wide driveway along Fonner Street to edge of ROW(approximately 12').
Owner: FEES
Description Date Amount
PFI Permit Fee 10/02/2018 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
RICH TINSEN
12797 SW 113TH PL
TIGARD, OR 97223
PHONE: 206-898-2299
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: See application
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12018-00267
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/1 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 OCT 0 2 2018
PUBLIC WORKS —ENGINEERING CITY OF TIGARD
NGINEERING
c Public Facility Improvement JYM vermit
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
❑ T1'I'E 1-Franchise Utility` �i.�rk
Check o1ie: F1 l tilities Sic}ev.alk%driver\=a\�approach ❑Streetimprovements performed by NWN, l'GE
and/or utility agenq}
Detailt:.cl description: %j2:;-T,4 1 t -�.�:: t,�..% �"l�, �l� �v-�.._t����J�
TYPE 2-Sidewalk/Drik,ewav/Sewer
�— Work performed for the purpose;of:
Sidewalk installarion or repair.
•
Property: address/location(s): 1 �- `1 `..3� ' tom/ 11.3 11-
1Driveway approach installation
1idlor repair
Sanitary sewer lateral installation
and/or main line tap
C! —t �� � .\ f_J TYPE 3--Full scale Dev=elopment
Applicant: !: York performed with Land use
Address: `�-_� � � ��� 1 l � �� l�C. approval which includes an}'of
Cit}/state: _ t t C c i`- Lip: the following:
l7 4t C� �r • Subdixisions car Partitions
hone:�'t�Cc- � \�'. ?.,?.� � Email: 2.��.__.�-��s��. ���_t,~,�.�.ra<: - c�4���..
' Street�\aldClllil�,+
Contact name: Phone:
• Mainline installation for Sanitary
Contractor: sewer, Storm sewer, Tigard water
-- -- and/or Tigard\Vatcr Service Area
CC.B#: Expiration:
Address: SUBMIT COMPLETED APPLICATION TO:
City/state: Zip: City of Tigard
Plat n i rig/f,rrgi n e eri ng
Phone: Email: 13125 SW Hall Blvd.
Contact name: Phone: Tigard,OR 97223
Applications f(.-sr"nT nor work in right.-of-\i'a.0
Engineer: Wily n1:11•be emailed to:
rowperrrlits&n tigard-or.gov
Address:
FOR STAFF USE ONLY
City/state: Zip:
Phone: Email: Case Flo.: FL,,.2=0je- 00-76:�-
Contact name: Application submittal fee of
Engineer s Estimate) S
Estimated value of work is required(if over$5,000): ' ' Additional fees: S
(\within the public right-of-way) application accepter.!:
�- 0
Is work related to a l:1ANDAJSE.DECISION? ❑ ��« <17 Bir: / S Date:
Application reviewed:
If so,please specify. (NI.LP,SDR,SL.TI3,etc.) case#: R
Bx,:--e Date:
i
Is work related to a.BUILDING PEIUMIT? ❑ Yes [A/N(:) Applicant notified:
0
If so,please specify-(BUILDING PER`11717)case#: Bv: kz Date:
I:\ENG\PermitApplications\p`i_auplicat+on Effective 19116/2017
,rq,0:5.«x.,.sxs., �..,rsw� ..e.:,;+.>to_.,vnz ,,,e C.LS::r-w<,.e'8.a.= xx>.•�,r.BkG.mrnr.:s.tavta�4&a':..�r,>f aux e;e..a .eh a.,.....�y..a<e`,'c:d.�tds:a.`...�.ev.as;-i...,. ,_, ».r..,.. ,,.._.a. ..r.., ...
Cityof Tigard • 13125 SW I-la.l.l blvd. • Tigard,Oregon 97223 u-Nvnat igard-ongov 503-718-249-1 Page 1 of 4
APPLICANTS
NOTE: Person specified as "Applicant."shall be designated"Permittee"and shall proy-ide financial assurance for work,it
required by the cite pursuant to TLMC: 15.041.140.
,. With the e\ception of a utilityoperating pursuant to a valid franchise with die City of Tigard,when the owner and the applicant are different
people,thc:applicant must be dit purchaser of rc.:cord ora lessee in possession with writren authoriz:stic,n from the owner or an agent of the
owner. The owner(s) must sitnl this application in the space provided or submit a written authorization with this application. Franchised
Urilities arc not required to obtain rbc:,)wncr's signature on the application
BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT:
• The abovc recluest clues not violate:ant,recr,rdcd deed restrictions that ma��be attached to Or imposed t112c7n the subject
ro pert%•.
• If the application is 7anted,the applicant will exercise the rights granted in accordance with the terms and subject to all the
conditions and limitations of the approval.
• All of the abore statements and the statements in ane plot plan,attachments,and exhibits transmitted herewith,are true,and
the applicants so acknowledge that any permit issued,based on this application,mati•he revoked if it is found that any such
statements are false.
• The;applicant has react the entire contents of the application,including;the policies and criteria,and understands the
'pct rements for approving:;or denk•ing the application.
Applicant/ALI tho ri zed Agent's signature Print name Date
SIGNATURES of each owner of the sul)ject property, if required.
Owner's Signature Print name Date.
Owner's signature: Print name Datt
Owner's signature: Print name Datc
PUBLIC FACILITY Ii1VLPROVEMENT PERMIT
City of Tigard • 1312-15 SW Hall Blvd. "1'i;;ard,(:)re�;on 972"?� wwwt€g;ard-ongov 503-718.2421 Page 2 of 4
DEVELOPMENT ENGINEERING FEES FOR STAFF USE ONLY
Public Facility Improvement(PFI)Permit:
DETAILED SUBMITTAL
REQUIREMENTS
APPLICATION FEE
Part 1: Required submittal fee$300.00 FRANCHISE UTILITY AND SIDEWALK/
PERMIT FEE DRIVEWAY AND UTILITY
Part 2: All non-water system irnprovements CONNECTIONS,ETC.
4 (work in the right of way)
Engineer's estimate X:-)')/o(less$300.00 submittal fee)
Engineer's estimate X 2".--o Plan Review Sketcb
(Includinginformation.below)
WATER SYSTEM FEE D Dimensions
Part 3: All public water system improvenleilts El Street Name
En
gineer's estimate X 12"' 0 Site Address
PFI Permit Fee Exemptions: FULL SCALE DEVELOPMENT
There will be no peri-nit fee charged,or assurance required (Subdivisions/Partitions and Street Improvements)
for the following types of work:
• Sidewalk repair(less than 20 lineal feet) Design Plans
• Relocate or replace mailbox (6 sets,24-66 or 2204)
• Ditch cleaning that does not involve regradlng.
• Weep hole repair. 0 Cover—Site,Vicinity,Abbreviation,Legend
• Curb repair or replacement(less than 20 lineal feet) ED General Notes(City,Water,Sewer,etc.)
• Lawn sprinkicr systern installation or repair F-1 Street(Plan,Profile)
• Street tree pruning or planting 0 Water,Storm and Sanitary(Plan Profile)
• Planter strip land0 Water Quality Facilitiesscape maintenance 0 Grading
• Test wells
El Landscaping/Tree Plan
El Composite Utilin,Plan(Electrical,Phone,Gas,
Note: A cash assurance may be required per Storm,Sanitary,Nater,Signage,Street fjjgits,etc)
TiVIC 15,04.140.(customer deposit) El Details
0 Traffic Sight Distance
0 Signing and Striping
EJ Street Light Plan and Photometric
EJ Engineers seal/signature
El Sheet label(project land use name,revision and
plan log block,dates and sheet numbers)
Additional Submittals
(per Land Use conditions)
El Traffic Report
El Storm water Drainage Calculations
0 Geotechnical Report
D Preliminary Access Report(Sight Distance)
0 Proposed Plat
El Pathway Design(if applicable)
D Water Department Approval
D Engineers Construction Estimate
PUBLIC FACILITY IMPROVEMENT PERMIT
City ofTigard 13125Sal'ILill Blvd. - Tigard,Oregonq7_123 - %vw--.v,.tJgard-or,gov - 503-718-2421 - Page 3of4
SAMPLE SKETCH:
Edge of P av emer t
I 'o Ditch "--'Op
Streetlight I ,.� .--._.-.—.--•—•----- -r----
I
>�Drainr ��
I I
' os cme�we`i"'C`iirie`'� 1
n'� � 1
�N Existing House
l I Existing
Li Driveway
I
R
I wti I � •
C 1
LL
I i
t � I
>'; 1
4 '
`1 Existing Shop
I fy C �V�� •
Power ala
i�
I
I -_..------77 6p�tt},-L ni e -----------
-
Fire Hydrant(FH)
I
Scale: 'I"-30'
t I I
I
I � I
I �
I I
I I (
MINIMUM SKETCH REQUIREMENTS (Put"N/A" if Not Applicable):
North arrow Property lines &dimension Slope of property
Street &street names) Existing building,structures Utility & street light boles
Proposed work Existing;curb car edue 'frees
"'Xisting S/W or of pavement I xistinll utilir.}°loCations
D/«` apron (sewer,water,storm)
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 1,1?5 S%V 1 Ja1l Bl.%-d. Ti�:ird C.)re on 9�'':� wv-w.t1'prd-or.gov • 501-718-242t Page 4 of 4
12797 SW 113th
NJ SITE SKETCH
157.89'
•
0
Oi
cD
•
• PROPOSED 20'X 12'DRI V E WA`(
SIRE htl'DR�4NT
O
w
Z PROPERTY LINE 140.73'
J
�I • • • • •0LMLITYPOLE
WI
aILI-
01 OI
a
FONNER STREET C.R. No. 495
PROPOSED SIDEW�tLK.REPOI.�R
ADDRESS CONTACT REFERENCE SURVEY I TAXLOTID# DRAWN AGE/NO.PAGES
12797 SW 113 PL. RICH TINSEN Plat Book 97 Page 42 2S103AC05000 1 OCTOBER 2018 1/2
TIGARD,OR (206)898-2299 Doc No.95039444
NOTES:
WO 5'MINIMUM SIDEWALK WIDTH REQUIRED BY CITY OF TIGARD
CCN 1 DWG.NO.142 NOT MET BY EXISTING SIDEWALK DUE TO LARGE
LO TREE IN R/W.PROPOSAL WILL REPLACE NARROW PORTION
LO BUT MAINTAIN CURRENT WIDTH.
O
O U MINIMUM BETWEEN ADJACENT PROPERTY LINE AND
Z 2 DRIVEWAY APPROACH CITY OF TIGARD DWG.NO.140
36.5'OF CURB AND GUTTER MATCHING EXISTING CURB AND
PROPOSED 20, x 22, O GUTTER TO BE REPLACED STARTING AT WEST PROPERTY LINE
rz�v�w�Y ALONG FONNER DR.PER CITY OF TIGARD DWG.NO.126
�
20'WIDE DRIVEWAY APPROACH MATCHING CURRENT
SIDEWALK GRADE PER CITY OF TIGARD DWG.NO.142
CORNER NOTE:
MARKER LOCATED 2"SW OF SOUTHWEST NEIGHBOR PROPERTY LINE EXTENDS TO EXISTING CURB LINE.
CORNER OF FENCE.IDENTIFIED AS CORNER ��7 J SIDEWALK TERMINATES ON THE PROPERTY LINE
NOTE 1 ON REFERENCED SURVEY
o E l�STI N O' oo� FENCE
rz/wL-1NE
S87046'00"W
C`d
4.51
a 0
CONTACT ADDRESS REFERENCE SURVEY TAXLOT DRAWN PAGE/NO.PAGES
RICH TINSEN 12797 SW 113TH PL. Plat Book 97 Page 42
(206)898-2299 TIGARD,OR Doc No.95039444 2S103AC05000 1 OCTOBER 2018 2/2
17 APRIL 1995
'rte
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