Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
PFI2019-00145
• • q TIGARD City of Tigard August 9, 2019 Dirtworks Excavation 2221 SE 53'Ave Hillsboro, OR 97123 Re: Permit No. PFI2019-00145 Dear Applicant The City of Tigard has processed a refund for fees on the above referenced permits) as follows: Site Address: 12180 SW Merestone Ct Project Name: Blagden Job No.: N/A Refund: ® Check#232909 in the amount of$300.00. ❑ Credit card"return"receipt in the amount of$ Note: Please allow 2-5 days for this refund transaction to be credited to your account by the company that issued your card. ❑ Trust account"deposit"receipt in the amount of$ Comments: Per applicant's request as a different contractor performed the work on this permit. Refund 100% of permit fees. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard-or.gov . ii . " City of Tigard TIGARD Accela Refund Request This form is used for refund requests of land use, development engineering and building permit application fees. Receipts,documentation and the Request for Permit Action form (if applicable)must be attached to this request form. Refund requests are due to Accela System Administrator by each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts Payable will route refund checks to Accela System Administrator for distribution to applicant. PAYABLE TO: Dirtworks Excavation DATE: 8/2/2019 2221 SE 53'Ave Hillsboro, OR 97123 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 423228 Case#: PFI2019-00145 Date: 5/2/2019 Address/Parcel: 12180 SW Merestone Ct Pay Method: CreditCard Project Name: Blagden EXPLANATION: Per applicant's request as new contractor performed the work and paid permit fees. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example:, 2300000-43104 $Amount PI'I Permit Fee 640-0000-43114 $300.00 TOTAL REFUND: $300.00 APPROVALS: SIGNA RES/DATE: If tinder$5,000 Professional Staff fi J-1-e---- If under$12,500 'Division Manager If under$25,000 Department Manager If under$100,000 City Manager If over$50,000 Local Contract Review Board FOR ACCELA,SYSTEM ADMINISTRATION USE ONLY Case Refund Processed: Date: ref/}7/g-/ By: I:\Building\Refunds\RefundRequest.doc x 09/01/2010 CITY OF TIGARD RECEIPT N ■ 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Blagden Site Address: �Tu _ Receipt Number: 436095 - 08/27/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF120 1 9-001 4 5 $-300.00 Total: $-300.00 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 232909 DHOWSE 08/27/2021 $-300.00 Payor: Dirtworks Excavation Total Payments: $-300.00 Balance Due: $300.00 Page 1 of 1 CITY OF TIGARD RECEIPT IL. 13125 SW Hall Blvd.,Tigard OR 97223 - 503.639.4171 rfGAP Project Name: Blagden Site Address: 10/1/ Receipt Number: 423228 - 05/02/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12019-00145 PFI Permit Fee 640-0000-43114 $300.00 Total: $300.00 PAYMENT METHOD CHECK# CC AUTH.CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 002345 PUBLICUSER284 05/02/2019 $300.00 Payer: SHERYL A DORTON DIRTWORKS EXCAVATION Total Payments: $300.00 Balance Due: $0.00 Page 1 of 1 RECEIVED MAY 202019 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT CITY OF TIGARD BUILDING DIVISION Request for Permit Action I !t A u I} 13125 SW Ball Blvd. •Tigard,Oregon 97223 • 503-718-2439 • www.tigard-ot.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@t'igard-or.gov FROM: ❑ Owner 0 Applicant l r l Contractor ❑ City Staff Check(1)one REFUND OR Name: INVOICE TO: (k''"indl"'dua0 Dirtworks Excavation LLC Mailing Address: 2221 SE 53rd Avenue City/State/Zip: Hillsboro OR 97123 Phone No.: 503-753-7562 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED(✓): CANCEL/V..QID PERMIT APPLICATION. 9-'Ve % - CQNT/24 Tt'A /9:6 6-721 Tel /5 74'7/7— REF UND P 1IT FEES (attach copy of original receipt and provide explanation below). FOR FEES DUE(attach case fee schedule and provide explanation below). 614 7v s r /= 7'�zri✓v ale /266/7 Permit#: PFI2019-00145 Site Address or Parcel#: 12180 SW Merestone Court,Parcel SEG664 Project Name: Blagden,Melissa M. Subdivision Name: Lot#: EXPLANATION: Contractor injured,unable to complete pOroject-refund requested of contractor pmt of$300.00 Signature: Date: 5/16/19 Print Name: bbie Joe Dort ,Jr. Brfimrl Policy 1. The dty's Community Development Director,Building Official or City Engineer may authorize the refund oc • Any let which was erroneously paid or collected. • Nut more than 80%of the application or plan review fec when an application is withdrawn or canceled before review effort has been expended. • Not more then 80%of the application or permit fee for issued permits prior to any inspection requests. 2. All refunds will be returned to the original payer in the form of a check via US portal service. 3. Please allow 3-4 weeks for processing refund requests. IOR Of I Ill I 5F: t)til,A RUutc co Sys.Aduun: Date By Route to Records: Date 6P C Refund Processed: Date of '//y ; By.6,LA,' invoke Processed: Date By Permit Canceled: Date Byt ---Parcel Tag Added: Date By I:\Building\Fowls\acgt'e mitActioa_1 Stioc CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PFI2019-00145 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Data Issued: 05/02/2019 TIGARD Parcel: SEG664 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: Blagden Project Description: Adjacent to 12180 SW Merestone Court. Emergency sewer repair with sewer connect located in cul-de-sac right-of-way. Owner: FEES Description Date Amount PFI Permit Fee 05/02/2019 $300.00 PHONE: Contractor: DIRTWORKS EXCAVATION 2221 SE 53RD AVE HILLSBORO, OR 97123 PHONE: 503-753-7562 FAX: Applicant: BOBBIE DORTON 2221 SE 53RD AVE HILLSBORO,OR 97123 PHONE: 503-753-7562 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. • PermitteelApplicant • I•• Signature: See application Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PFI2019-00145 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-TRAFFIC CONTROL SPECIFICATIONS Applied Notice Applicant shall provide traffic control according to the current edition of the"Manual on Uniform Traffic Control Devices [MUTCD]for Streets and Highways", U.S. Dept.of Transportation, FHWA,current edition,American Traffic Safety Services Association[ATSSA],and Oregon Temporary Traffic Control Handbook[OTTCH]. PFI_Sidewalk/[ 06-TRAFFIC CONTROL PLAN Applied Notice Submit a job specific traffic control plan. A copy of the approved traffic control plan shall be readily available at the work area.Traffic control devices,flag persons, etc., shall be in place prior to initiation of construction work and shall be effectively maintained. PFI_Sidewalk/[ 07-TRAFFIC CONTROL ROAD CLOSURE Applied Notice Public roadway shall not be closed to traffic, at any time,without obtaining written approval from the City Engineer. The applicant is responsible to provide 48 hour advance notice of traffic flow disruptions to affected businesses, residents and area wide Emergency Services: 503-629-0111 (Tigard Police Dept.,Tualatin Fire&Rescue)and to 503-962-8140(Tri-Met) and 503-431-2345(Tigard School District)and other service providers impacted by such closure. PFI_Sidewalk/[ 08-TRAFFIC CONTROL ADVANCE WARNING Applied Notice Advance warning of traffic disruption shall be provided to the public by placement of an approved advance notification sign at each end of the construction area 72 hours(min.)before initiation of construction work. PFI_Sidewalk/[ 09-TRAFFIC CONTROL PROPERTY ACCESS Applied Notice Access to existing properties shall be maintained at all times,including normal delivery service and mail service. Obtain City approval of any access closures. PFI_Sidewalk/[ 10-TRAFFIC CONTROL WORK HOURS Applied Notice Work is permitted in daylight between the hours of 7:00 a.m.to 7:00 p.m.Mon-Fri unless otherwise authorized by the City. PFI_Sidewaik/[ 11 -TRAFFIC CONTROL LIMITED WORK HOURS Applied Notice Hours of construction work on collector and arterial roads will be limited to 9:00 a.m.to 3:00 p.m.unless authorized by the City Engineer. Work will not be permitted on collector and arterial roads between 3:00 p.m.to 9:00 a.m.unless authorized by the City Engineer. PFI_Sidewalk/1 12-TRAFFIC CONTROL MODIFICATION Applied Notice The City reserves the right to add to or modify traffic control requirements as necessary to effectively control traffic and to assure public safety. PFI_Sidewalk/[ 13-DRAINAGE CONTROL Applied Notice Drainage shall be controlled within the work site and shall not adversely affect adjacent private property, public properly and the receiving system. The City may at any time order corrective action and suspension of work to accomplish effective drainage control. PFI_Sidewalk/[ 14-UTILITY NOTIFICATION Applied Notice Oregon law requires following the rules adopted by the Oregon Utility Notification Center. Said rules are set forth in OAR 952-001-0100 through OAR 952-001-0080. Copies of said rules may be obtained from the Center by calling 503-246-1987. If you have any question about the rules,contact the Center. NOTE: Damage to utilities shall be corrected at the permit holder's expense PFI_Sidewalk/1 15-UTILITY LOCATION CONFLICT Applied Notice Applicant must verify all existing utilities for both vertical elevation and horizontal location prior to start of work(pothole before digging if necessary). Should conflicts arise and redesign or relocation of facilities be necessary, it shall be done at the applicant's expense. Changes must be approved by the City in advance of work.Applicant shall coordinate the work with affected utility agencies. PFI_Sidewalk/[ 16-TEMPORARY PATCH Applied Notice A temporary hard-surface patch shall be placed on trenches within roadways at the end of each work shift. Obtain advance approval of patching method. No trench shall be left at any time in an un-safe condition. Applicant is responsible for and is liable for hazards or damage resulting from the prosecution of the work. PFI_Sidewalk/[ 17-REPAIR OF EXISTING FACILITIES Applied Notice Work under this permit shall include repair of existing facilities(roads,ditches,etc.)as may be necessary,as determined by the Inspector,to overcome deterioration or damage which occurred in conjunction with the work authorized by the permit. Corrective work shall be done at the applicant's expense. PFI_Sidewalk/[ 18-SEWER SYSTEM TEST Applied Notice A sewer system air-test and/or DVD T.V.test report and one set of"As-Builts"shall be provided for review and approval. PFI_Sidewalk/[ 19-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 20-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/[ 21 -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/[ 22-DAILY INSPECTION REPORTS Applied Notice Applicant shall submit daily inspection reports,on a weekly basis,to the City's Inspector. PFI_Sidewalk/[ 23-MONUMENT PROTECTION Applied Notice Existing monuments, property corners,and survey markers shall be protected. Replacement shall be at the permit holder's expense. PFI_Sidewalk/[ 24-VALIDATION OF MATERIAUCONSTRUCTION Applied Notice The City's Inspector may, at his discretion,require tests and or reports from the applicant to validate claims of material or construction adequacy/compliance. Such tests/reports shall be provided at the applicant's expense. PFI_Sidewalk/[ 25- 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/[ 26- RIGHT OF ENTRY/EASEMENTS Applied Notice Applicant to obtain proper right-of-entry and/or easements prior to starting work. Proof of right-of-entry or properly executed easements,shall be provided to the City. The City shall in no way be construed to be liable for the applicant's failure to obtain or provide for proof of right-of-entry or easements. PFI_Sidewalk/[ 27- PRIVATE PROPERTY AGREEMENTS Applied Notice Provide the City a copy of an executed agreement[s]from the owner for each private property disturbed by construction activity. PFI_Sidewalk/[ 28-AS-BUILT DRAWING Applied Notice One as-built drawing showing all new public improvements,including any revision made to the previously approved construction plans and,also, any improvement which may impact an existing public system or facility,shall be provided to the City by a registered civil engineer along with an engineer's certification of installation compliance(Certificate of Compliance). PFI_Sidewalk/[ 31 -OTHER Applied Notice Other City of Tigard RECEIVED PH #: PPA.- 0/9- Od/171 IIIm ENGINH RING I)U,PARTMEI Y 0 2 2019 TIGARD Public Faciliti, a , ment (PFI) Permit PROJECT INFORMATION TYPE OF WORK Project name: Blagden ❑ TYPE 1—Franchise utility Work Brief description of project. g y sewer repair with performed by ti,Ptili or utility y'y agency sewer connect located in cup-de-saq right of way ❑ TYPE 2—It(AVSidewalk/Driveway/Sewer Work pertiamed for the purpose of: • Sidewalk installation Of repair • Driveway approach installation and repair SITE INFORMATION &le • Sanitary sewer lateral installation and Location (address if available): 12180 SW estone main hoe tap ❑ TYPE 3—lull Scale Development \%ork Tigard, Oregon - Tax map/parcel no.: 1 S134CC00900 performed with land use approval which includes all of the following: • Subdivisions or Partitions APPLICANT INFORMATION • Street widening Name: Melissa Blagden & Shervin Zarebabakandi Mainline installation for sanitary sewer, storm sewer, Tigard water, and Tigard mailing address: 12180 SW Merestone Ct waater service area City/state: Tigard OR zip: 97223 ❑ TYPE a—Small Cell Technology 0 TYPE 5-T igard'Triangle Phone: Email: Phone: NOTE: Type 1 and 2 applications mar be Rebecca Kramer, HomeSmart Realty Contact name: mailed too,rrwpeentitsth Ilgard-tort^%'. Phone: 360-597-8650 Email: rebeccakreo©gmail.com CONTRACTOR INFORMATION 0 Same as applicant Name: Bobbie J. Dorton, Jr. Dirtworks Excavation LLC CCI3 Number: 220245 Mailing address: 2221 SE 53rd Avenue City/State: Hillsboro ORzip: 97123 Phone: 503-753-7562 Email: dirt.works@icloud.com ENGINEER INFORMATION Name: Mailing address: City/State: Zip: Phone: Email: ADDITIONAL INFORMATION Estimated value of work is required (if over$5,(k10):$ n/a (within the public right-of-way) Is work related to a LAND USE DECISION? ❑Yes ❑No Case number: City of Tigard • 13125 SW Hall Blvd, • Tigard,Oregon 97223 • wwwtigard-orgov • 503-718-2421 • Page 1 of 4 APPLICANTS NOTE: Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for work,if required by the city pursuant to'HAG 15.04.140. • With the e ccptiun of a utility rpx wing pursuant to a valid franchise or license with the City of'I iganl,when die nwtlrr and the applicant arc different people,the applicant must be rite purchaser of record or a lessee in possession with written atttharizati,st front the owner or an agent of the owner, The owner must sign this application in the space provided or sul,mit a written authorization with this application. Franchised or Licensed Utilities are not required to obtain the owner's signature on the application. I, the applicant,certify that: • To the best of my knowledge,all the information provided within this application package is complete and accurate. • The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject property. • • If the application is granted,I will exercise the rights granted in accordance with the terms and subject to all the conditi ns and limitations of the approval. mot , 42/17 phcant's or au prized agent's signature Print name Date Property• owners signature (if required) Print.name ?ate STAFF USE':ONLY h .�• Case No: 1 �al tp�1 � Permit fee: - ' r .b Received by: 4, Date: Ir<, j a Approved by: .- Date: t. ,�'- /771' Notified by; k Date: C"-2. City of Tigard • 13125 SW Hall Blvd. • 'Tigard,Oregon 97223 • Wwwtigard-or.gov • 503-718-2421 • Page 2 of 4 ,A i Vicinity Map V MapTitle am, ,, ' �' City of Tigard, Oregon r�'a , _ it 1 1 "' Sanitary Manhole 4 y ' T r .✓..3 f In 5l1YKe i• µ:A# r . ,..- § _ New ConXNRbn § "? Sanitary Flow Arrows — r" In Service ', . � ,f 1., Abandoned 1 • Sanitary Main . :3-f — In Service v < New ConrtrvRion _? Abandoned ' — Sanitary Lateral , r aw W- MIND 3" !.: -'1l l ...'1 hr&' '7.r';311 Li '( - ,, gg y 0 7 g i', . n ` l I r r e A i . Stale. 0.02 Mika. City of Tigard Hall 13125 SW H Blvd %'" i Tigard. OR 97223 Map Created (503)639•41 71 . II,<,,1t 11 `1 05,022019 www.tigard-or.gov CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12019-00145 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2421 Date Issued: 05/02/2019 Parcel: SEG664 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: Blagden Project Description: Adjacent to 12180 SW Merestone Court. Emergency sewer repair with sewer connect located in cul-de-sac right-of-way. Owner: FEES Description Date Amount PFI Permit Fee 05/02/2019 $300.00 PHONE: Contractor: DIRTWORKS EXCAVATION 2221 SE 53RD AVE HILLSBORO, OR 97123 PHONE: 503-753-7562 FAX: Applicant: BOBBIE DORTON 2221 SE 53RD AVE HILLSBORO, OR 97123 PHONE: 503-753-7562 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 PFI2019-00145 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-TRAFFIC CONTROL SPECIFICATIONS Applied Notice Applicant shall provide traffic control according to the current edition of the"Manual on Uniform Traffic Control Devices [MUTCD]for Streets and Highways", U.S. Dept. of Transportation, FHWA, current edition, American Traffic Safety Services Association [ATSSA], and Oregon Temporary Traffic Control Handbook[OTTCH]. PFI_Sidewalk/[ 06-TRAFFIC CONTROL PLAN Applied Notice Submit a job specific traffic control plan. A copy of the approved traffic control plan shall be readily available at the work area. Traffic control devices, flag persons, etc., shall be in place prior to initiation of construction work and shall be effectively maintained. PFI_Sidewalk/[ 07-TRAFFIC CONTROL ROAD CLOSURE Applied Notice Public roadway shall not be closed to traffic, at any time, without obtaining written approval from the City Engineer. The applicant is responsible to provide 48 hour advance notice of traffic flow disruptions to affected businesses, residents and area wide Emergency Services: 503-629-0111 (Tigard Police Dept., Tualatin Fire& Rescue) and to 503-962-8140 (Tri-Met) and 503-431-2345 (Tigard School District) and other service providers impacted by such closure. PFI_Sidewalk/[ 08 -TRAFFIC CONTROL ADVANCE WARNING Applied Notice Advance warning of traffic disruption shall be provided to the public by placement of an approved advance notification sign at each end of the construction area 72 hours (min.) before initiation of construction work. PFI_Sidewalk/[ 09-TRAFFIC CONTROL PROPERTY ACCESS Applied Notice Access to existing properties shall be maintained at all times, including normal delivery service and mail service. Obtain City approval of any access closures. PFI Sidewalk/[ 10-TRAFFIC CONTROL WORK HOURS Applied Notice Work is permitted in daylight between the hours of 7:00 a.m. to 7:00 p.m. Mon-Fri unless otherwise authorized by the City. PFI_Sidewalk/[ 11 -TRAFFIC CONTROL LIMITED WORK HOURS Applied Notice Hours of construction work on collector and arterial roads will be limited to 9:00 a.m.to 3:00 p.m. unless authorized by the City Engineer. Work will not be permitted on collector and arterial roads between 3:00 p.m. to 9:00 a.m. unless authorized by the City Engineer. PFI Sidewalk/[ 12-TRAFFIC CONTROL MODIFICATION Applied Notice The City reserves the right to add to or modify traffic control requirements as necessary to effectively control traffic and to assure public safety. PFI_Sidewalk/[ 13- DRAINAGE CONTROL Applied Notice Drainage shall be controlled within the work site and shall not adversely affect adjacent private property, public property and the receiving system. The City may at any time order corrective action and suspension of work to accomplish effective drainage control. PFI_Sidewalk/[ 14- UTILITY NOTIFICATION Applied Notice Oregon law requires following the rules adopted by the Oregon Utility Notification Center. Said rules are set forth in OAR 952-001-0100 through OAR 952-001-0080. Copies of said rules may be obtained from the Center by calling 503-246-1987. If you have any question about the rules, contact the Center. NOTE: Damage to utilities shall be corrected at the permit holder's expense PFI_Sidewalk/[ 15-UTILITY LOCATION CONFLICT Applied Notice Applicant must verify all existing utilities for both vertical elevation and horizontal location prior to start of work(pothole before digging if necessary). Should conflicts arise and redesign or relocation of facilities be necessary, it shall be done at the applicant's expense. Changes must be approved by the City in advance of work. Applicant shall coordinate the work with affected utility agencies. PFI_Sidewalk/[ 16-TEMPORARY PATCH Applied Notice A temporary hard-surface patch shall be placed on trenches within roadways at the end of each work shift. Obtain advance approval of patching method. No trench shall be left at any time in an un-safe condition. Applicant is responsible for and is liable for hazards or damage resulting from the prosecution of the work. PFI_Sidewalk/[ 17-REPAIR OF EXISTING FACILITIES Applied Notice Work under this permit shall include repair of existing facilities (roads, ditches, etc.) as may be necessary, as determined by the Inspector, to overcome deterioration or damage which occurred in conjunction with the work authorized by the permit. Corrective work shall be done at the applicant's expense. PFI_Sidewalk/[ 18-SEWER SYSTEM TEST Applied Notice A sewer system air-test and/or DVD T.V.test report and one set of"As-Builts"shall be provided for review and approval. PFI_Sidewalk/[ 19- 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/[ 20- 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/[ 21 -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/[ 22-DAILY INSPECTION REPORTS Applied Notice Applicant shall submit daily inspection reports, on a weekly basis,to the City's Inspector. PFI_Sidewalk/[ 23-MONUMENT PROTECTION Applied Notice Existing monuments, property corners, and survey markers shall be protected. Replacement shall be at the permit holder's expense. PFI_Sidewalk/[ 24-VALIDATION OF MATERIAL/CONSTRUCTION Applied Notice The City's Inspector may, at his discretion, require tests and or reports from the applicant to validate claims of material or construction adequacy/compliance. Such tests/reports shall be provided at the applicant's expense. PFI_Sidewalk/[ 25- 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/[ 26- RIGHT OF ENTRY/EASEMENTS Applied Notice Applicant to obtain proper right-of-entry and/or easements prior to starting work. Proof of right-of-entry or properly executed easements, shall be provided to the City. The City shall in no way be construed to be liable for the applicant's failure to obtain or provide for proof of right-of-entry or easements. PFI_Sidewalk/[ 27- PRIVATE PROPERTY AGREEMENTS Applied Notice Provide the City a copy of an executed agreement[s]from the owner for each private property disturbed by construction activity. PFI_Sidewalk/[ 28-AS-BUILT DRAWING Applied Notice One as-built drawing showing all new public improvements, including any revision made to the previously approved construction plans and, also, any improvement which may impact an existing public system or facility, shall be provided to the City by a registered civil engineer along with an engineer's certification of installation compliance (Certificate of Compliance). PFI_Sidewalk/[ 31 -OTHER Applied Notice Other r - . RECEIVED IliCity of Tigard PFI#: PicA— DOI�}S = I NGINI ERING DEPAR'1'MEI\AY 0 2 2019 Public Facilitc�."iA� rt�.,;, � est PROJECT INFORMATION TYPE OF WORK Project name: Blagden 0 TYPE 1—Franchise Utility Work Emergency repair with performed by NWN' fl Ik , or utility Brief description of project: g y sewer agency sewer connect located in cul-de-saq right of way 0 TYPE 2—ROW Sidewalk/Driveway/Sewer Work performed for the purpose of: • Sidewalk installation or repair • Driveway approach installation and repair SITE INFORMATION S? _._ 6,611 • Sanitary sewer lateral installation and Location (address if available): 12180 SW estone t main line tap 0 TYPE 3—l:ull Scale Development Work Tigard, Oregon - Tax map/parcel no.: 1 SI 34CC00900 performed with land use approval which includes any of the following: • Subdivisions or Partitions APPLICANT INFORMATION • Street widening Name: Melissa Blagden & Shervin Zarebabakandi • Mainline installation for sanitary sewer, storm sewer, Tigard water, and "Tigard Mailing address: 12180 SW Merestone Ct water service area City/State: Tigard OR zip: 97223 0 TYPE 4—Small Cell Technology 0 TYPE 5—ligard"Triangle Phone: Email: Phone: NOTE: Type 1 and 2 applications may be Rebecca Kramer, HomeSmart Realtyemailed to rowpermits(I tigard-or.utn. Contact name: Phone: 360-597-8650 Email: rebeccakreo@gmail.com CONTRACTOR INFORMATION 0 Same as applicant Name: Bobbie J. Dorton, Jr. Dirtworks Excavation LLC CCB Number: 220245 Mailing address: 2221 SE 53rd Avenue Cin•/State: Hillsboro OR Zip: 97123 Phone: 503-753-7562 Email: dirt.works@icloud.com ENGINEER INFORMATION Name: Mailing address: City/State: Zip: Phone: Email: ADDITIONAL INFORMATION Estimated value of work is required(if over$5,000):$ n/a (within the public right-of-way) Is work related to a LAND USE DECISION? 0 Yes 0 No Case number: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 1 of 4 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 15.04.140. With the exception of a utility operating pursuant to a valid franchise or license with the City ofTigard,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 must sign this application in the space provided or submit a written authorization with this application. Franchised or licensed Utilities are not required to obtain the owner's signature on the application. I,the applicant,certify that: • To the best of my knowledge,all the information provided within this application package is complete and accurate. • The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject property. • If the application is granted,I will exercise the rights granted in accordance with the terms and subject to all the conditions and limitations of the approval. 4 /014/1/1-- .111.0 • plicant's or au orized agent's signature Print name Date Property owner's signature (if required) Print name Date STAFF USE ONLY •` 1 Case No: IF- 0 —I_I Permit fee: - e5 /e-re, Received by: AS Date: Approved by: .w" Date: e.3,2/r Notified by: .S Date: C2- t 9 City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 2 of 4 Vicinity Map c c .�,-la � ' Ma Title_Beaverton . ..� ' 4- - �. r x Tigard �" 1_1 • City of Tigard, Oregon ^ 0 • rSanitary Manhole --I • ,A1 r s_ �T w In Service TuaIaiin - • s New Construction Sanitary Flow Arrows >f .�+�Aso3 #� F P '► In Service �, ti )� Abandoned A ,_ . 1 , kk Dimwit. L pie - .__ iilaSanitary Main - In Service '•s• F _ y New Construction a Abandoned 4r.4, 4 -1AL • tO — Sanitary Lateral , ...)4,47' irt 1 . , . ,r. 4 q,''' .� ' I �ti t t ^ r • - ` r.`` -.. mak... I ' ._ - 40411i ' 1. - - ..a. .'*, 1 LJlg 1WO)iiiV . .t y 4. ' los, ti n.. F -tom.T ti e •• yF., tr,.. \...../...../ I k' . t -_-- ` x I --i,iFIc 1 • I • �, +• Data is derived Dom multiple sources.The Crly of Tigard makes no warranty.representation n.or gu aranleo as In — i •` �y I�p�'r��.I.7a ■ Ihp Ekes not.accuracy I r ellntat OI f.r nuateneh,Of tanv o `"'�'-�"T'�'� j of the data provided herein The City of T y pro Tigard shall , . � S _Yf assume no Iiahilily for env errors,omissrons r a �y �Y inaccuracies In the Information provided regardless Si }' I -'l how caused . . dt 1 ;1 lt.r, . • ,:......,, t � ti I i I \ .I s �I i vti _ •_ \ l -41„,-.:,- lI ft Scale: 0.02 Miles l _ II L. ilii- City of Tigard "T '` 13125 SW Hall Blvd • w ` "� Tigard, OR 97223 I Map Created: (503) 639-4171 i' TIC,ARn .ems ,_ I 05/02/2019 www.tigard-or.gov CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT 'II • COMMUNITY DEVELOPMENT Permit#: PFI2019-00145 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 05/02/2019 T f ,r11;17 g Parcel: SEG664 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: Blagden Project Description: Adjacent to 12180 SW Merestone Court. Emergency sewer repair with sewer connect located in cul-de-sac right-of-way. ,ppnt et O� -..1/�J/ h) , ,„,ri C� .,c7 r- 1�» n. / / 9 ,Llr Owner: FEES Description Date Amount PFI Permit Fee 05/02/2019 $300.00 PHONE: Contractor: CLOG BUSTERS LLC 2900 SE CORNELIUS PASS RD, STE 549 HILLSBORO, OR 97123 PHONE: 503-680-8947 FAX: Applicant: TRICIA WOLFE 2900 SE CORNELIUS PASS RD HILLSBORO, OR 97123 PHONE: 503-680-8947 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 PFI2019-00145 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-TRAFFIC CONTROL SPECIFICATIONS Applied Notice Applicant shall provide traffic control according to the current edition of the"Manual on Uniform Traffic Control Devices [MUTCD]for Streets and Highways", U.S. Dept. of Transportation, FHWA, current edition, American Traffic Safety Services Association[ATSSA], and Oregon Temporary Traffic Control Handbook[OTTCH]. PFI_Sidewalk/[ 06-TRAFFIC CONTROL PLAN Applied Notice Submit a job specific traffic control plan. A copy of the approved traffic control plan shall be readily available at the work area. Traffic control devices, flag persons, etc., shall be in place prior to initiation of construction work and shall be effectively maintained. PFI_Sidewalk/[ 07-TRAFFIC CONTROL ROAD CLOSURE Applied Notice Public roadway shall not be closed to traffic, at any time,without obtaining written approval from the City Engineer. The applicant is responsible to provide 48 hour advance notice of traffic flow disruptions to affected businesses, residents and area wide Emergency Services: 503-629-0111 (Tigard Police Dept., Tualatin Fire&Rescue)and to 503-962-8140(Tri-Met) and 503-431-2345(Tigard School District)and other service providers impacted by such closure. PFI_Sidewalk/[ 08-TRAFFIC CONTROL ADVANCE WARNING Applied Notice Advance warning of traffic disruption shall be provided to the public by placement of an approved advance notification sign at each end of the construction area 72 hours(min.)before initiation of construction work. PFI_Sidewalk/[ 09-TRAFFIC CONTROL PROPERTY ACCESS Applied Notice Access to existing properties shall be maintained at all times, including normal delivery service and mail service. Obtain City approval of any access closures. PFI_Sidewalk/[ 10-TRAFFIC CONTROL WORK HOURS Applied Notice Work is permitted in daylight between the hours of 7:00 a.m.to 7:00 p.m. Mon-Fri unless otherwise authorized by the City. PFI_Sidewalk/[ 11 -TRAFFIC CONTROL LIMITED WORK HOURS Applied Notice Hours of construction work on collector and arterial roads will be limited to 9:00 a.m.to 3:00 p.m. unless authorized by the City Engineer. Work will not be permitted on collector and arterial roads between 3:00 p.m.to 9:00 a.m. unless authorized by the City Engineer. PFI_Sidewalk/[ 12-TRAFFIC CONTROL MODIFICATION Applied Notice The City reserves the right to add to or modify traffic control requirements as necessary to effectively control traffic and to assure public safety. PFI_Sidewalk/[ 13-DRAINAGE CONTROL Applied Notice Drainage shall be controlled within the work site and shall not adversely affect adjacent private property, public property and the receiving system. The City may at any time order corrective action and suspension of work to accomplish effective drainage control. PFI_Sidewalk/[ 14-UTILITY NOTIFICATION Applied Notice Oregon law requires following the rules adopted by the Oregon Utility Notification Center. Said rules are set forth in OAR 952-001-0100 through OAR 952-001-0080. Copies of said rules may be obtained from the Center by calling 503-246-1987. If you have any question about the rules, contact the Center. NOTE: Damage to utilities shall be corrected at the permit holder's expense PFI_Sidewalk/[ 15-UTILITY LOCATION CONFLICT Applied Notice Applicant must verify all existing utilities for both vertical elevation and horizontal location prior to start of work(pothole before digging if necessary). Should conflicts arise and redesign or relocation of facilities be necessary, it shall be done at the applicant's expense. Changes must be approved by the City in advance of work.Applicant shall coordinate the work with affected utility agencies. PFI_Sidewalk/[ 16-TEMPORARY PATCH Applied Notice A temporary hard-surface patch shall be placed on trenches within roadways at the end of each work shift. Obtain advance approval of patching method. No trench shall be left at any time in an un-safe condition. Applicant is responsible for and is liable for hazards or damage resulting from the prosecution of the work. PFI_Sidewalk/[ 17-REPAIR OF EXISTING FACILITIES Applied Notice Work under this permit shall include repair of existing facilities(roads, ditches, etc.)as may be necessary, as determined by the Inspector, to overcome deterioration or damage which occurred in conjunction with the work authorized by the permit. Corrective work shall be done at the applicant's expense. PFI_Sidewalk/[ 18-SEWER SYSTEM TEST Applied Notice A sewer system air-test and/or DVD T.V.test report and one set of"As-Builts"shall be provided for review and approval. PFI_Sidewalk/[ 19-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/[ 20-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/[ 21 -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/[ 22-DAILY INSPECTION REPORTS Applied Notice Applicant shall submit daily inspection reports, on a weekly basis, to the City's Inspector. PFI_Sidewalk/[ 23-MONUMENT PROTECTION Applied Notice Existing monuments, property corners, and survey markers shall be protected. Replacement shall be at the permit holder's expense. PFI_Sidewalk/[ 24-VALIDATION OF MATERIAL/CONSTRUCTION Applied Notice The City's Inspector may, at his discretion, require tests and or reports from the applicant to validate claims of material or construction adequacy/compliance. Such tests/reports shall be provided at the applicant's expense. PFI_Sidewalk/[ 25-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/[ 26-RIGHT OF ENTRY/EASEMENTS Applied Notice Applicant to obtain proper right-of-entry and/or easements prior to starting work. Proof of right-of-entry or properly executed easements, shall be provided to the City. The City shall in no way be construed to be liable for the applicant's failure to obtain or provide for proof of right-of-entry or easements. PFI_Sidewalk/[ 27-PRIVATE PROPERTY AGREEMENTS Applied Notice Provide the City a copy of an executed agreement[s]from the owner for each private property disturbed by construction activity. PFI_Sidewalk/[ 28-AS-BUILT DRAWING Applied Notice One as-built drawing showing all new public improvements, including any revision made to the previously approved construction plans and, also, any improvement which may impact an existing public system or facility, shall be provided to the City by a registered civil engineer along with an engineer's certification of installation compliance(Certificate of Compliance). PFI_Sidewalk/[ 31 -OTHER Applied Notice Other