PFI2020-00062 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
s COMMUNITY DEVELOPMENT Permit#: PF12020-00062
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 02/20/2020
Parcel: SEG3446
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Vallereux Sidewalk Repair
Project Description: Adjacent to 14550 SW 130th Ave. Replace 5'x 15'6"sidewalk.
Class of Work: FEES
Type 2-Sidewalk/Driveway Approach Description Date Amount
PFI Permit Fee 02/20/2020 $300.00
Total $300.00
Owner:
REQUIRED INSPECTIONS
Call 503-639-4175 for the IVR inspection request line or visit the City of
PHONE: Tigard website at www.tigard-or.gov to schedule inspections online.
Contractor:
JAY JACOB MILLER
8152 SW HALL BLVD#240
BEAVERTON,OR 97008
PHONE: 5037074725
Applicant:
JAY MILLER
8152 SW HALL BLVD#240
BEAVERTON,OR 97008
PHONE: 5037074725
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 1\
Signature:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12020-00062
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/1 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/1 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/1 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/1 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/1 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 and 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/1 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/1 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/C 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/1 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/1 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/1 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/1 19-PRECONSTRUCTION MEETING Applied Notice
Before initiating any construction activity,the applicant shall coordinate with the City's inspector,Trent Brickey at
503-718-2686,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/C 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/1 22-DAILY INSPECTION REPORTS Applied Notice
Applicant shall submit daily inspection reports, on a weekly basis,to the City's Inspector.
PFI—Sidewalk/1 23-MONUMENT PROTECTION Applied Notice
Existing monuments, property comers,and survey markers shall be protected. Replacement shall be at the permit holder's
expense.
PFI—Sidewalk/1 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
City Of Tigard RECEIVED
FEB 19 2020
i PUBLIC WORKS—ENGINEERING CITY OF TIGHRD
Public Facility Impr0verft6fifGMI`Permit
DESCRIPTION OF WORK(in the right-of-way) TYPE OF WORK
Check one: ❑ Utility Connection
❑ Sidewalk/driveway approach ❑ TYPE I—Franchise Utility Work
Work performed by NWN,PGE
O Street" r/ and/or utility agency.
(O M
Detailed description 1-7E2—Sidewalk/Driveway/Scorer
Y Work performed for the purpose of
Sidewalk installation or repair.
Driveway approach installation
Property ddress/location(s): /�� 5/1 �` and/or repair
• Sanitary sewer lateral installation
and/or main line tap
TYPE 3—Full scale Development
Applicant Work performed with Land use
Address: approval which includes any of
the following:
Cit}•/state: 1 Zip:
Subdivisions or Partitions
Phone: Email: • Street widening
Contact narne: Phone: • Mainline installation for Sanitary
sewer,Storm seater,Tigard coater
Contractor and/or Tigard Water Service Area
CCB#: Ira on: aid SUUaTCOMPIZI*gnwrrtlCAMONTO:
Address:
City of Tigard
City/state: zip: P/amrieg/Eaglam-ug
Phon m 13725 SW Hall Blvd.
'Tigard,OR 97273
COIItdCL name:' Phon Applications for"minor work in right-of-way."
t only may be emailed to:
Engineer:
Address:
City/state: Zip:
Phone: Email: Case No,; Ag'-22-aw- QQD&.e
Contact name: Application submitral fee: A96,00
Additioml fees:
Estimated value of work is required(rf over$5,000): Application accepted:
(within the public right of-watt) By: kA Date
Is work related to a LAND-USE DECISION? p hes 1 Application reviewed:No Z/r 9 t 2bZ0
By: - " 3 Date
If so, please specify (MLP,SDR, SUB, etc.) case #:
Applicant notified:
Is work related to a BUILDING PERMTP ❑ Yes �No By: Date
If so,please specifil(BUrLDING PERMIT)case#: v unM.a>�u>naw.aov 'w mJ®«5
City of Tigard • 13125 SW Hatt Blvd. • Tigard,Orej{on 97223 • wwwdprd"oLgov • 503-718-2421 • Page 1 of 4
APPLICANTS
NOTE: Person specified as"Applicant"shall be designated"Permitted'and shall provide financial assurance for work.
When the owner and the applirsnt are diffcrmt people,the apphcant must be the purchaser of record or a lessee in possession with written
attthO&Atk n from the owner or an agent of the owner The owners)must sign this application in the space provided or submit a written
XUdX datum with this application.
BY SIGNING BELOW,THE APPLICANT(S) SHAD.CERTIFY THAT:
• The above n3Mcst does not violate ang drM rcstnctions that MU be attached to or inmosed 1M=thesubject proms
• if the application is granted,the apphcant will exercise the tights 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 the plot plan,attachments,and exhibits transmitted herewith,are true;and
the applicants so acknowledge that arty permit issued,based on this application,may be revoked if it is found that any such
stntcmcnts are false.
• The applicant has read the entire contents of the application,including the policies and criteria,and understands the
requirements for approving or denying the application.
SIGMA RES of cach owner of the subject property required
ii 1Q,t� l fL6 .Y� .2,fi
Appli is s' P ' a 4 Date
�^ t r� la 0701
Owners signature Priv awe Date
Owners signature Print name Date
O wn&s signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard 13125 SW Hall Bh,& • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2421 • Page 2 of 4
DEVELOPMENT ENGINEERING FEES
Public Facility Improvement(PFI)Permit:
INITIAL PFI PERMIT FEE
Part 1: Required submittal fee is 10%of the Net PFI Permit Fee.See below for calculations.Minimum of$300.
NET PFI PERMIT FEE
Part 2: All non-water system improvements engineer's estimate X 7%(less the initial PFI Permit Fee).
WATER LINE CONSTRUCTION FEE
Part 3: All public water system improvements engineer's estimate X 12%.
FOR STAFF USE ONLY • ' STAFF USE ONLY
TYPE 4: SMALL WIRELESS FACILITY TYPE 1-3:DETAILED SUBMITTAL
REQUIREMENTS
CHECKLIST
Does applicant have a right-of-way license? ❑Yes ❑No TYPE 1 AND TYPE 2 - Must include a sketch
showing:
Under the wireless facilities standards,is the proposal
❑ Dimensions
considered?(check all that apply): ❑Small Cell ❑Macro
❑ Street Name
How many install sites are proposed as part of this permit El Site Address
application?
TYPE 3-Must provide 4 sets of plans (sized 24 x 36
or 22 x 34) and an electronic version of all submittal
The proposed equipment is located on which of the following. items. The plans must that include:
❑Public Right-of-Way ❑Private Property
❑ Cover—Site,Vicinity,Abbreviation,Legend
If equipment is to be located on private property,describe the ❑ General Notes(City,Water,Sewer,etc.)
type&use: ❑ Street(Plan,Profile)
❑ Water,Storm and Sanitary(Plan Profile)
❑ Water Quality Facilities
❑ Grading
❑ Landscaping/Tree Plan
❑ Composite Utility Plan(Electrical,Phone,Gas, Storm,
Sanitary,Water,Signage,Street lights,etc.)
❑ Details
❑ Traffic Sight Distance
❑ Signing and Striping
❑ Street Light Plan and Photometric
❑ Engineers seal/signature
❑ Sheet label(project land use name,revision and plan
log block,dates and sheet numbers.)
❑ Engineer's Construction Estimate
Additional Submittals
(per land use conditions,if applicable)
❑ Traffic Report
❑ Storm water Drainage Calculations
❑ Geotechnical Report
❑ Preliminary Access Report(Sight Distance)
❑ Proposed Plat
❑ Pathway Design
❑ Water Provider Approval
City of Tigard 13125 SW Hall Blvd. Tigard,Oregon 97223 • www.tigard-or.gov • 503-715-2421 • Page 3 of 4
Q gin- '•�- '� � I
Edge of Pavement
I +� Ditch
Streetlight I —•—•—•—•—•.•—•.��•�
I �
I I I 1
I-�ro�SiF d'S�tA�iTIR�-' j
I
Iy I (,E . Existing House
,j I Existing
FI Q i
O>I Driveway
1 " ,
CI
al I ,: 4!
I I i aJ r l
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co 1
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Powerpale I I 13
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Fro a Line L
Fire Hydrant(FH)
I 771 I
Scale: ]"=30'
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TYPE 1
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• TYPE 2:
REQUIREMENTSMINIUM SKETCH
North arrow Property lines&dimensions Existing utilities locations
(sewer,storm,water)
Street&street names All existing structures
Proposed work Existing curb or edge of pavement Utility&street light poles
Existing S/W or D/W apron Slope of property Trees
Cityof Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 4 of 4
Sidewalk EST.NO. i�(}' A
RepairPROPOSAL Tao
-- specialist
8152 SW Hatt Blvd#240 sideviafkrepairs@gmaii.com Phone:503-70".472,
CCB# 198613 Beaverton,OP 97008 http:J,,www.sidewaUkreaairs.net
Eliminate Trip Hazards G r eAr�'e1 pr AA 4l 1 W%T-
Property owners are responsible for the repair and maintenance of the sidewalks adjacent to their property.Avoid the costs,danger
and hassles of being involved in a trip hazard lawsuit for personal injury.Your neighbors,children on bicycles or skateboards, nev
mothers with baby carriages,disabled people in wheelchairs and everyone else have one common need:A smooth,safe sidewalk.
Let our experienced professionals grind out trip hazards or replace sidewalk sections as needed.
Name: SAe It ey Va I(Crew)(
uSe o R1vf a Sr9+tiS'
Address: /4 S 5 0 VV d?►l
Ae IV
Phone: 601-49q—/.114 Emaii:5 t JJeqA ogft.0 _ G
�� 'babtotsi's
Areas: ^� Est.L Ft.:
Other: (`dfAL r S 5 6 D �
L uh d Pol To AL I+f s So I
I
i25 tleiralk Repis semen! Rc Loll q 5k5Areas: 1 Est.L Ft.: 3 Est.Sq Ft.::7,�j
Other: S aW G K1.5 _ lOd M&
starwet� j,
it
cw4g
-N0^atard area to S!C'Pet Der ADA 5'ar'^_a,:n '�Ct.�cS a .SCC' cC_` _ -? �.eri�!S ^a e5
Sidewalk Replacement
TK'ece en:GYe eY,S•'y --ee -:C3 5..:e.:d.t ''L nr :at)or
!>'••dY1mu TJ.PrCv-'�,e. l5ta.d^:r. :5n 3�'`a.e or,�ev.b,.ate.�er^r;5 3 C ni^_.B,r�1i xrcC)o�'.Ocnt} e.,_r9T4-^C5.
Warranty
CCnt'aCCOr wdndn(S-dCe"d!dnC+.•O'+c cn5'1--�r0'a:e"'t�C !';P'e'D?'v"e'y:n�OnStflCC�O'1�O'.F-aLtOr577d'.^•"Yc'e"'9'1!5.
Disclaiawr
"•NevCy ground c0•ncrete a neem reaiacec cov::ete w':' ''ave a C F`ef^-'ac?xa'ance tha, Oc:ea. - •�' a r
)' SL'ty D„E tSE.. Ji IiSCev^:Xe:: n:-2:iY
CdnnOC DP feS{7onS!ble�or'uture sci:'^ove-en;`-a-CeP rocas o'oth= _Yfi+C�+1�5_^Fy7;'1C�•!CD'It"C:�'QSu:.�tier;. di-1'.acS..8..
Acceptance of Proposal
The above p^ces 5ae:•`tat ons aj'.e^o Cons.,e a:cez P- S cev-aie Repa r 4zeGaGst s avt"-nn t _e^FC:^ [ e :O"t nS OLS ,e..u-c. Pa`Ta�C 5
cue uoC-'1co-a,eto ne55 Ztriev,Se-ote,.B•.;re"agreest=:a,Z.'costs o :xtecFani,nr��' caCtcostsa eya;'ees.
Payr^ent may de^ace 7;check' SK a.ac nr V, ,,ta 51,en'a•^
buyer Signature: a Date:
Contractor Signature: Date: I D
S'9-Gr aCeno"re Qes y.••..:e r o
INITIAL HERE:
DATE p6WDDMYYYI
ACO" CERTIFICATE OF LIABILITY INSURANCE 1009-
THIS
1 9THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: K the cartiflcete holder is an AODtTIO"ItnNAL INSURED,the policy(lec)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain poiicles may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder In lieu of succh orsemen s).
PRODUCER kAME=--- --' — -
PII°"E 503 258 1448
CHAMBERLAIN INSURANCE AGENCY FAX No: 503 256.5825
-- --
7831 SE Stark St #102 ADo Fss mtotar chamberlalninsurance.c�rr
Portland, OR 97215 __ eiauRER1aJA►FOROtN000VERAOE_-_ �' °--
sURERA— Contractors Bonding and Ins Co
---- ---------- et -
INSURED
JAY JACOB MILLER INSURERc:
8152 SW Hall Blvd#240
BEAVERTON,OR 97007 IRaURERE_---- 1
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COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 4 __
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IIIRINNH1111l1NUf11/IttIf1NU(UI1IlIUfININNIIt1UflUlNU/RHNIIfIlU71U!U! SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
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