PFI2021-00010 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12021-00010
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 01/11/2021
Parcel: SEG590
Jurisdiction:
Site address:
Subdivision: Lot:
Project: 51351-WO 866849
Project Description: Place fiber cable for Fred Meyer service order 11565 SW Pacific Hwy
Class of Work: FEES
Type 1 -Utilities(gas, electric, data) Description Date Amount
Total
Owner:
REQUIRED INSPECTIONS
Call 503-639-4175 for the IVR inspection request line or visit the City of
PHONE: Tigard website atwww.tioard-or.00v to schedule inspections online.
Contractor:
PHONE:
Applicant:
RUSSELL WELLS
4155 SW CEDAR HILLS BLVD
BEAVERTON, OR 97005
PHONE: 5033127330
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: L,�&
I&"
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12021-00010
Tvoe: Condition Name: Status: Severity:
PFI_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 19-PRECONSTRUCTION MEETING Applied Notice
Before initiating any construction activity,the applicant shall coordinate with the City's inspector,Trent Brickey at
971-228-9269,to establish a preconstruction meeting.
Please call 503-639-4175 to schedule inspection, use code 738
PFI_Utilities 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_Utilities 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_Utilities 22 -DAILY INSPECTION REPORTS Applied Notice
Applicant shall submit daily inspection reports, on a weekly basis,to the City's Inspector.
PFI_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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 Utilities 28-AS-BUILT DRAWING Applied Notice
1,2,3,4,5 28-AS-BUILT DRAWING
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).
1,2,3,4,5 28-AS-BUILT DRAWING
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).
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—Utilities 31 -OTHER Applied Notice
Other
City of Tigard pE#: PF12021-00010
ENGINEERING DEPARTMENT
Public Facilities Improvement (PFI) Permit
PROJECT INFORMATION
n T11aE OF'X ORK
Project name: "I"�7T ❑ WPE 1-Frar chiar t titin Rad:
Ilnef descn tical of projett: prdomwdbr N\\'N.PGE.and/m
' lJohm .
❑ T)PE 2-ROW
Ias(.< SWT'DVAt' 1�6t�1 Sidewalk/Ih tea plrwer4
pnfomrrd for the purpose of
• Sidra-,dk insmEau<m or repair.
SITE INFORMATION Darrv%appmxb inatanAtenr
and mpatz
L� ncm 'address if avul.tldel:
• Suutan•seance lateral ius[aDadrnr
bnr up
-. ❑ TYPE3- -u a ve gnuar.,
\\cd,pertomed with Laud use
APPLICANT INFORMATION appxaa]aduclr uwludes mn of
dle f"Hou,mg.
Name: 14 �a � � Subdm idm or Part tiros
Mailing addre+.: �� � (J„S I • St+ra a�idrturg
•hiairdine ir,W.Raiira+ Brr Smriian
CIty/`tate: _ Ltp: � over.Stomr n m Tigard water and
„• �� Tigard Warr Sen'icr:1tea
Phone: 1ri/�1L
y,���� ��y�k�•y� ' ��'���- ❑ T5PE7-Small l:rO TrclutnlcV'
EiTwl:{I {►•j4dk-C4 t hf�tne:�+--�—�� ❑ WPE5-Tigard Triangle
Contact n.d-tc: jag6a 1 1_.
Phone: 50;-4tz-TS5U -tdA----- Email: "r wtw4l5 -24�+Lpfkt �---
CONTRACTOR INFORMATION ❑ Same as applicant
Name: _ mer.
Mailing address: Cin,/State. Zip:
Phone: Email:
ENGINEER INFORMATION
Name: I —_--
\flailing address: Cin/Start- Lip:
Phone: b mad:
ADDITIONAL INFORMATION
Estimated value of work is required(if over S5,000):$ "-------- (within the public right-of-way)
is work related to a LAND USE DECISION? O 1'es *Nto Case number.
Ciry of Tigard • 13125 SW Hall Blvd. • Tigard,Omgon 97^"3 • waurigaalor.gov 503-718-2421 • Page t of a
APPLICANTS
NOTE: Person specified as"applicant"shall be designated"Permittee"acid shall provide financial assurance for
work,if required by dte city pursuant to n1C 15,(4.11().
A'uh the execpum of a utility-ct—wig pur<uaut fo a raW fraaduse oe license with the Cir of 11gud.l*M the Darns and the applicua
are diffmnt psWk,the applicaen must be the purchaser of record or a Iv.see in possession 11th antrrn authotizatiou from the miner
or an agmt of dic olves ILe Olins must awn flus applicautm m the space ptonded or submit a%nn= authotuaum with this
applicatim ptm¢lurod ut ljcevsed l ulaws are nra"Tared to obwa the(raner's sigumure am ale application.
I,the applicant,certify that:
• To the hest of my knowledge,all the information provided within dus application package is complete and
accurate.
• The above request does not violate an) recorded deed restrictions that ma} 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.
li�
-. 's �iK5�t6.�Ur is-< _1 21 ZI
.lppli authorized agent's signature Print name Date
Property owner's signature(if required) Print name u
STAFF USE ONLY
Case No: PF12021-00010 Pnntt tcc: Received by: HPollard Date:
Approved by:�'"_- Date: 1/71UZJ Notified by.�Date: I I
City of Tlgerd • 13111 SW Hall Blvd. • Tigard.Ore{.oii 97123 • er tvwngardor.fior • F013-718-2421 • Page 2 of 4
DEVELOPMENT ENGINEERING FEES
Public Facility Improvement(PFI)Permit:
INITIAL PFI PERMIT FEE
Part 1: Required submittal fee iS 1 cw•of the Net PH Permit Fee.See below for calculations Minimum of"JO,
NET PFI PERMIT FEE
Part 2: All non-water sysieni unpn tvenents enprteer's estimate S 70 a;less die untJ PFI I'etmit Fee;
(PATER LINE CONSTRI'CT'ION FEE
Pan3: allpublic uucrcri; rioveintnrsengineer estimateS1T'.-
WIRELESSFOR STAFF USE
NLY FOR STAFF[ISE ONLY
TYPE 4:SMALL
• I 1 i 1 I
REQUIREMENTSrrTALFACIUTYCHECKLIST
kws applicant have a right-of-war 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): O Small Cell ❑Macro ❑ Street Name
How many install sites ace proposed as part of this permit ❑ Sac Address
apphcationr
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 fbKowirW items. The plans must that include:
0 Public Right-of--Way ❑Ptivate Property
❑ C-over—Site.\icutin-,Abbreviation,legend
If equipment is to be located on private property,describe the ❑ (',eneral Notes(Cin,Water,Sewer,etc.)
type&use: ❑ Street(Plan,Pcnfile)
❑ Water,Storm and Sanitary(Plan Profile)
❑ Water Quality Facilities
❑ Grading
❑ landscaping/Trec Plan
❑ Composite L'ahty Plan(FJectrieal,intone,Lias,Storm,
Sanitary,Water.Sigrtage.Street Lights,etc.)
❑ Details
❑ Traffic Sight Distance
❑ Signing and Striping
❑ Start light Plan and Photornenic
❑ I:aghteers seal/signature
❑ Sheet label(project land use name,recision and plan
log block,dates and sheet aumbcm)
❑ Faiginecls Gonstmction F_rtimatc
Addfrianaf Submittals
(perland use conditions,if applicable)
❑ Traffic Report
❑ Storm water Drainage Calculations
❑ Geotechnical Report
❑ Prelim nary Access Report(Sight Distance)
❑ proposed Plat
❑ Pathway Destgn
❑ Water Provider Approval
CityofTigurd 131255\\ IiailBhd. Tigard,Oregon 97213 • a�awngard4jcgcv • 5U3-7182421 • Page3of4�
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Street a street names _.0 existing structures
proposed work —Existing curb or edge of pavement Utility&street light poles
_Existing S/lC'or D/W apron _Slope of propertTrees
City of Tigard • 13125 SW Hall Blvd. Tigard,Orcgon 97223 • w�ugardocgov • %3-718-2421 • Page 4 of 4
- I
—JOB SITE
KROGERS(FRED MEYER)
BF+1I.� 11565 SW PAIFIC HWY(9W
NO JOINT POLE NOTE (17R .MTALAALA 4ITrre°x°uas
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2-THIS JOB REQUIRES- GRo VICINITY MAP
COOT.,CITY OF TIGARD fV
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1-THIS WO IS METRO E SERVICE
PRDER DRIVE ASR 3377466
2-THIS JOB REQUIRES 2020 METRO E BLANKET
ODOT,CITY OF TIGARD 51351-5255669-116 0 xuXX==
PERMITSO xvimwrac
CUSTOMER-KROGERS(FRED MEYER) o xuun nor sv.axxvn
11565 SW PACIFIC HWY(99W) o xc eLwwr XLgmaeX
PORTLAND(TIGARD),OR SO1P''POI'`
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CONSTRUCTION CONTACTS ASR 3377466
DAVID CARNLEY-971-940-9000ASSIGN- SHEET 1 OF 3
JAMES STAATS503-758-3119 o s o o ewcN
BBFTP FDTd99502 NORTH 0 0 0<an
SCHEDULING CONTACT TGRDORXA FC2038,415 0 0 OFPIX1IIgt
RYAN ROBERTS-503-643-3713e°Lxr or cnrrAn
TGRDORXA BBFTP H1002,72-PORT 1 Aurwvreau
FACILITIES CONTACTLCON-
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LAUREL KIELTY 42528ALT LC
3-4006 LISAST JOHN360-852-0507
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ALT ON-CORPORATE NOC 513387-7800 -
INSPECTION CONTACT xciciia au®wLua
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RON HAYHURST 503.292-3345
PXJNC XO
ENGINEERING CONTACTLABOR HOURS MATERIAL REQUIREMENTS vvueLX e.
RUSS WELLS 503-312-7330 SPLICE-C-1494-2/X-0 I Z' yfiber
CREW-C-32W-WX-0 BW1500'TAI PORT TERMINAL
FLAGGERS-24 HOURS 7001500 TAIL
INSPECTOR-0 HOURS 700 FT IF 1X FIBER DROP 51351-W0888849 TGRDORXA/ASR 3377466
SONICOM WORK 2W OF 1.25'SD 11565 SW PACIFIC HWY
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SPLICING NOTE.
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\\ RUN"RED JUMPER"AT TGRDORXA H1002
LOCATED AT 7275 SW HERMO60 WAY OFF
A 661 022007 OF SW 72ND AVE SIO SW DARTMOUTH
218 FIBER
TGRDORXA H7002,1-98+TGRDORXA FC2038,427.432+
TGRDORXA H1002,103147+XD,148-173+TGRDORXA
H1002,234-238+XD,179-180+TGRDORXA FC2038,433.435+
XD,182-167+TGRDORXAH 1002,250-276
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144 FIBER SHEET 20F 3
TGRDORXA H1002,1-14+XD,15+TGRDORXA H1002,16.98+
TGRDORXA FC2038,427-432+ NORTH
TGRDORXA H1DO2,103.106+XD,07-113+TGRDORXA
H1002,114122+XD,179-180+TGRDORXA FC2038.433.435+
XD,182-187+TGRDORXAH I D02,250-276
144 FIBER
TGRDORXA H1002,1-14+XD,15+TGRDORXA H1002,16-71+
XD,72-76+TGRDORXA H1002,77-95+TGRDORXA FC2038,427-432+
TGRDORXA H1002,103108+XD,07-113+TGRDORXA
H1002,114-122+XD,179-180+TGRDORXA FC2038,433435+
XD,182-187+TGRDORXAH1002,25D-278
NOTE-SPLICERS-CUT DARK 51351-WO866849 ziply g fiber
TGRDORXA H1 DD2,72-78 TO FIELD TGRDORXA/ASR 3377488
IN 144 FIBER 11565 SW PACIFIC HWY
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0 TERM 10
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ZIPLY TAG 58335 BBGTD DEB,201-250+XD BBGTD DEB,124-150
C1136A6981-PGE 51-75+BBGTD DEB 1276-300 237' AE.5a22
TAG KROGER(FRED MEYER) BBGTD DEB,27"00
11565 SW PACIFIC HWY NEW FIBER CABLE AE25-22
SONICOM TO PLACE C 1500 FIBER TAIL
700'OF AERIAL IX FIBER TGRDORXA H1002, 258'
DROP INTO KROGER 72-76+XD,6 BBGTD DEB,201-250
UIPMENT F G NEW FIBER TERMINAL AE'50-22
1.25
PLACE 200'OFF 1.25
SUBDUCT THRU ROW OF p SPORT FIBER TAIL TERM
TREES-MINIMAL TREE BBFTP FDT 499502
TRIM AS NECESSARY TGRDORXA H1002. /
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RISER POLES-ACCT CODE CHANGE
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TGRDORXA/ASR 3377488
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PEDESTRIAN/BICYCLE SAFETY ESCORT REQUIRED
TONO E AT WORK SITE WHILE CONSTRUCTION WORK IN PROGRESS
,140fOA Op P 6\ ODOT DIAGRAM 820
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/ REFERENCE
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SIGN SPACING AND BUFFER LENGTHS
POSTED SPACING BETWEEN SIGNS BUFFER
SPEED A B C SPACE
20 100 100 1
350 350 35
45
50 500 500 5001210
55
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SHEET 1 OF 1
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