PFI2019-00063 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
.111
s • COMMUNITY DEVELOPMENT Permit#: PFI2019-00063
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 02/25/2019
Parcel: 2S103CD02500
Jurisdiction: Tigard
Site address: 13775 SW 116TH PL
Subdivision: HOLLYTREE Lot: 7
Project: Voytko Sidewalk Repair
Project Description: 13775 SW 116th Place. Repair approximately 9 square feet of sidewalk.
Owner: FEES
Description Date Amount
PHONE:
Contractor:
BRIDGE CITY CONCRETE&ASPHALT INC
20 NE HOGAN DR
GRESHAM, OR 97030
PHONE: 503-860-2856
FAX:
Applicant:
DAVID NEWLAND
20 NE HOGAN DR
GRESHAM, OR 97030
PHONE: 503-860-2856
Total $0.00
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: � rppLACCd1UVA
Issued :
B -
Y
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PFI2019-00063
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/[ 09-OTHER Applied Notice
RECEIVED
City of Tigard FEB 2 5 2019
`' PUBLIC WORKS —ENGINEERING CITY OF TIGARD
�� PLANNING/ENGINEERING
TIGA_
RD Public Facility (PFI) Permit
0 c mE --.—': -Z=. —_yam' -s",..'=m- SY:".?i
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
❑ TYPE 1-Franchise Utility Work
Check one: ❑ Utilities X Sidewalk/drivewa41.1.(1,-
y approach El� Streetimprovements performed by NWN, PGE
S` ,Qu lJk a - le and/or utility agencyDetailed descriBption: /
IS rk. 1 if •e-4`, set ��#4.r.1�4 . {p ld Jit -'TYPE 2-Sidewalk/Driveway/Sewer
Work performed for the purpose of
• Sidewalk installation or repair.
Property address/location(s): 13276 5 W i1(."1'i121.
• Drnapproach installation
and//oror rreepair
i74_04 44 • Sanitary sewer lateral installation
and/or main line tap
Applicant .>e7e (AAl fiYc �C ) ❑ TYPE 3-Full scale Development
Work performed with Land use
Address: approval which includes any of
City/state: Zip: the following.
Phone: Email
; • Subdivisions or Partitions
Contact name: Phone:
• Street widening
• Mainline installation for Sanitary
Contractor: 13ri Niel. �1d rT
J Lt• 6 _ _\ /�S 17T 1 /AC, sewer, Storm sewer,Tigard water
and/or Tigard Water Service Area
CCB#: Expiration: 7" d i
Address: 79 NE , r-' -
D r. suBau COMPLETED APPUCATION To.
City/state: $Sig- w. a - /� Zip: 97030 City of Tigard
Phone:5 -140.--140.-2411. O44.1,eeh
ZEmail:
e tid e� Freie.r1t.¢, Planning/Engineering
/ 13125 SW Hall Blvd.
Contact name:pAvio A[6.1.JL..11:I4) Phone: –160-240 Tigard,OR 97223
Applications for"minor work in int-of--way"
Engineer only may be emailed to:
Address: row)erntits gard-or�
Cl /Bt1tC: 1*OR sr-11.1 1'�I. l)N t l
ty p:
Phone+ Email: Case I`To PFI 2 oI q_-co��
Contact name: •kpphca.on submittal fee(07%of
E ngmeei s Estimate) ;
Estimated value of work is required(if over$5,000):$ 1 i d 0 ...-V Additional fees $
(within the public right-of-way) Application accepted
By .- Date 2451 i q
Is work related to a LAND-USE DECISION? ❑ Yes 1tig No
Application re-,,iewed
If so,please specify(MLP,SDR,SUB,etc) case#:
By -4Date 1.5 1
Is work related to a BUILDING PERMIT? ❑ Yes -No Applicant nota&
If so,please specify(BUILDING PERMIT)case#: By Date .. 12C-- K1
l-\ENa\rermitApplicatrons\ph_apphcation 9&sbn10/16hA17
City of Tigard • 13125 SW Hall Blvd • Tigard,Oregon 97223 • wwwtigard-or:gov • 503-718-2421 • Page 1 of4
APPLICANTS
NOTE: Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for work,if
required by the city pursuant to TMC 15.041.140.
* With the exception of a utility operating pursuant to a valid franchise with the City of Tigard,when the owner and the applicant are different
people,the applicant must be the purchaser of record or a lessee in possession with written authorization from the owner or an agent of the
owner. The owner(s)must sign this application in the space provided or submit a written authorization with this application. Franchised
Utilities ate not required to obtain the owners signature on the application
BY SIGNING BELOW,THE APPLICANTS)SHALL CERTIFY THAT:
• The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the Subject
• If the application is granted,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 above statements and the statements in any 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 is 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
requirem . appro' •,.r den,' ; the application.
A. cant/Authorized Agent's signature Print name Date
SIGNATURES of each owner of the subject property,if required.
Owner's signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
_ CSS r r T.c -'�T=.1..
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 2 of 4
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