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PFI2020-00087 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12020-00087 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 03/10/2020 Parcel: 2S 111 AB04700 Jurisdiction: Tigard Site address: 9165 SW INEZ ST Subdivision: PENMAR TERRACE Lot: 14 Project: Reynolds Sewer Project Description: 9165 SW Inez Street. Replace sewer from cast iron transition to city main via burstisleeve. Class of Work: FEES Type 2-Sidewalk/Driveway Approach Description Date Amount PFI Permit Fee 03/10/2020 $300.00 Owner: Total $300.00 REQUIRED INSPECTIONS Call 503-639-4175 for the IVR inspection request line or visit the City of PHONE: Tigard website at www.tioard-or.00v to schedule inspections online. Contractor: SANITECH LLC 201 SHIRLEY ST MOLALLA, OR 97038 PHONE: 5038031207 Applicant: ERIC HEFLEY 201 SHIRLEY ST MOLALLA, OR 97038 PHONE: 5038031207 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: ✓r' n Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12020-00087 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/1 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/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/[ 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/[ 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/1 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/1 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/1 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/1 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 RECEIVED MAR 0 9 2020 City Of Tigard CITY OF TIGARD P7 ENGINEERING DEPARTMENT 1%!NINGIENGINEERINC Public Facilities Improvement (PFI) Permit PROJECT INFORMATION [ y TYPE OF WORK Project name: �� �� �`1 k2 ❑ TYPE 1-Franchise Utility Work pcsfonnedbyNWN,PGE, or utility Brief description of project: agency TYPE 2-I:OW Sidewalk/Driveway/Sewer Work performed for the purpose of: v • Sidewalk installation or repair • Driveway approach installation and repair SITE INFORMATION Y-• Sanitary sewer Literal installation and 11 _ 1 main line rap lail location (address if avable). b l4 L� S w ���` "" ❑ TYPE 3—Full Scale Development Work performed with land use approval which J includes any of the following. .mow • Subdivisions or Partitions, APPLICANT INFORMATION • Street widening • Mainline installation for sanitary sewer, Name: storm sewer, Tigard water, and 'Tigard Mailing address: P- �"x watcT service area ❑ TYPE 4-Small Cell Technolofn� City/State:����? �%� gip' ��b ❑ TYPE 5—"1 i}nrd'L'riangle Phone: "r7y�J � t�(�J-- Emall:�w J �C �� ^0&00:4 Phone: St � al� t-) _JS� NOTE: Tvpe 1 and 2 applications may be _ - emailed rn r nvpernutsGdtiin -or..uc. Contact name: Vl Phone: C O Email: CONTRACTOR INFORMATION MSRMC as applicant lns'9 Name: -. L -f r`af0 h l � 0- ' CCB Number: - P(-,' ' 1 Ci State: D� to (J Zip: C� -1 6M Mailing address: K" �i ��-�- ' City/ State: �D Email: /i ENGINEER INFORMATION Name: Mailing address: City/State: _ zip: Phone: Email: ADDITIONAL INFORMATION Estimated value of work is required(if over$5,000):$ 2GC)' G Q (within the public right-of-way) Is work related to a LAND USE DECISION? O Yes (�lo Case number: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-ongov 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 francl se or he with rhe City of'f gard,when he owner and the applicant F. different people,the applicant must be the purchaser of record or a lessee in possession with written authorization from the owner <x an agent of the owner. Thr owucr must sign this application to the space provided or submit a written authorv'.arion with this application Franchised or Licensed Utilities are not regmrcd 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 tights granted in accordance with the terms and subject to all the conditions and limitations of the approval. Date App ant's or authori7 agent's r iature Print name Date Print name Property owner s signature (if required) teas� F0 0C Received b F t Date Case No: �� Permit fee: — y r r =,��12o2 O Notified by: Date: Approved by: Date: City of Tigard • 13125 SW Hall Blvd. Tigard,Oregon 97223 wwwtigard-c ngov • 503-71&2421 Page 2 of4l 2011 Edition Page 85 Stationary Lane Closure with Flagging Diagram 320 Y $ � o ro w c��u 0 ZOE d Oz¢=d O O I r 0) W WI1 LL o a • I � l� I ••• ` a� dC I • O a I � I I • `q o f affe 1 1 I �p • o¢� a`� I � I • 3 I o :® b8 • m aid # I •• +. I CL Z • I oto r j • 0—< I a U. < I wa 0)" I I wady_ in mwo I� ---------- I • a f' V J m M On o +n Sign Spacing and Buffer Lengths(feet) • p Q` O Pested S acin Between Si ns Buffer ? Speed A B c---j space 0. 20 50 a2� 100 100 100 75 5 00 10035 3 ,; ! �'> 350 350350 125 zY- 40 150 45 180 500 500 500 210 1, n3?' 4 ff December 2011 Chapter 5 x 71, fL � :--•--"' +rsr3r� hi a�.c .,h .,, r � -A d t a r .r��•,t 3 ��s��v5�i��a v���xs �v�53{ y ' r ' r*2r.`r��a{'1�j :f �..aM��•y,�,AA,�i-ti � �S: 4�r.�„c4 Mx o-xi qt t`�>• ar� U :rt y,x+'T�y�4§y F �✓ ���"�a € s r "r=> T"' -♦[t _ dA v �.=1 rx t . e Z t raS,dy w y t s `➢ t � i�r�1vn"�.Iv � o P�, z IrrF^ aim-• -�..-v -w,� ,f > r 7 ����� MS �,�,� ��� ��a � � �1 �7 �'s � �ad � � � � ��� �� � � � k _� � � � i Q- �_ _ _ _ _ _ - '� I � � �___ -� _---- 4�- � 1 '� P`��S i-ot,-o� w�� ��r 5 4717' iiC /u Office 503-213-4775 Eric Cell 503-803-1207 Customer • Name: Site location • Phone: �U\© y`nO�ca 9165 SW Inez St. \.9� �,Q • Email: Tigard,OR.97224 CO\`V Realtor Washington God Washington County J • Louise Levin • 503-502-6502 • touise(aegA-tY rouu corn Work to be performed as follows: *Install sanitary sewer from cast iron transition to city main via burst/sleeve. *Excavate(1)3'x5'hole in roadway,not to exceed 10'in depth. *Excavate(1)3'x5'hole in front yard,not to exceed 3'in depth. *Replace with 4"HDPE,ABS,3034 with appropriate fittings per city code. *Material on property will be placed on plywood and used for backfill. *Due to utilities and pipe work in excavation area some settling may occur after bac Sanitech Sanitech is unable to compact soils without damaging settling. g g the utilities and pipe work and will not be responsible for any *Material in roadway will be hauled off and replaced with Y,minus rock. *Compaction test included. *Removal and replacement of asphalt in roadway included. *Traffic control plan(Fiaggers)included in price. *Sanitech is not responsible for root damage in excavation area. *No landscape restoration. *All labor,material,property and right of way permit included in price. CITY OF TIGARD PLUMBING PERMIT COMMUNITY DEVELOPMENT Permit#: PLM2020-00106 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 03/09/2020 Parcel: 2S111AB04700 Jurisdiction: Tigard Site address: 9165 SW INEZ ST Project: SEWER LINE Subdivision: PENMAR TERRACE Lot: 14 Project Description: REPLACE SANITARY SEWER LINE FROM CAST IRON TRANSITION TO CITY MAIN VIA BURST/SLEEVE, Contractor: SANITECH LLC Owner: REYNOLDS,JEROME G&OLIVIA J 201 SHIRLEY ST 9165 SW INEZ ST MOLALLA, OR 97038 TIGARD, OR 97224 PHONE: 503-803-1207 PHONE: FAX 503-303-8238 FEES Quantity Description Date Amount 60 If Sanitary Sewer 03/09/2020 $62.54 Specifics: 1 12%State Surcharge- 03/09/2020 $8.70 Plumbing Type of Use: SF 10 ea Minimum Fee Adjustment- 0310912020 $9.96 Class of Work: ALT Plumbing Type of Const: Occupancy Grp: Stories: Total $81.20 Required Items and Reports(Conditions) This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR Specialty Codes and all other applicable law. All work will be done in accordance with approved plans This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232.1987 or 1 800 332.2344. Issued By: Permittee Signature: Call 503.639.4175 by 7:00 a.m.for the next available inspection date. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. SANIT-3 OP ID: MC DnrE(MMr CERTIFICATE OF LIABILITY INSURANCE 03/09/2020 THIS 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: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Premier NW Insurance NAME: Megan Clegg 421 HI h St#200 PHONE 9 (AIC.No,EX1:503-655-9364Ax — Oregon City,OR 97045 E-MAIL AX: o:503655-2035 W.Mike Moll ADDRESS:mcleg @premiernw.net INSURERS AFFORDING COVERAGE NAIL N INSURER A:American Fire&Casualty Co 24966 INSURED o47 LLC PO Box 4INSURER B:SAIF Corp 36196 PO B — Molaila,OR 97038 INSURER c;Ohio Casualty Insurance CO 24074 INSURER D: _ INSURER E: _ INSURER F 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. INSR TYPE OF INSURANCE POLICY EFF POLICDY EXP LIMITS POLICY NUMBERIMNl GENERAL LIABILITY ' EACH OCCURRENCE S 1,000,000 A X coMMPRcIaL GENERAL uaBlurY BKA 55399864 03M 51202D'03/15/2021 PREMISES Ea occurrence $ 1,000,000 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 15,00 PERSONAL d ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,00 GENT.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,00 PJBorrowed& LICY X PRO' LOC _. - -- S MOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,00 ANYAUTO BAA 55399664 03M6/2020 03M512021 BODILY INJURY(Par person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED AUTOS ER AC DENTAGE $ Comp/Coll Ded $ $5001$1,00 UMBRELLA LIAR OCCUR EXCESS LIAR I EACH OCCURRENCE S 2,000,000 CLAIMS-MADE USO 55399684 03/15/2020 03/15/2021 AGGREGATE $ 2,000,00 ED X RETENTION 01 ERS COMPENSATION $ MPLOYERS'LIABILITY ,,IN X TWC STATU. X TH- ROPRIETOR/EXELUDR/EXEcunvE❑I 77156 01/01/2020 01/01/2021 $ 1,000,000 EWMEMBER EXCLUDED? .NIA E.L.EACH ACCIDENT atory In NH) describeunder E.L.DISEASE-EA EMPLO S 1,000,00 RIPTION OF OPE RATIONS below E.L.DISEASE-PDLICV LIMIT S 1,000,00 wed&Rented BKA 55399684 03/15/2020 03/1512021 Limit 164,50 ment Ded 50 i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space IS required) Operations of the named insured subject to policy conditions, limitations, and exclusions. CERTIFICATE HOLDER CANCELLATION CITY 015 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Tigard ACCORDANCE WITH THE POLICY PROVISIONS. 13125 Hall Blvd Tigard,OR 97223 AUTHORIZED REPRESENTATIVE cz-&E_ ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(201010) The ACORD name and logo are registered marks of ACORD