PFI2020-00385 Perm ii- vapP-enrni+ no-f- rquu ii-en+. d.
City ofTigard Mc Pa ‘ks pnv
ir ENGINEERING DEPARTMENT `. PH#: 2020-00385
LARD Public Facilities Improvement (PFI) Permit
PROJECT INFORMATION
TYPE OF WORK
Project name: P029XC053
• TYPE 1—Franchise Utility Work
Brief description of project: Troubleshooting Sprint equipment on performed by NWN,PGE, or utility
agency
a cell tower.A manlift is required to reach the equipment.The lift will be • TYPE 2—ROW Sidewalk/Driveway/Utility
parked in the road for a couple hours,requiring a TCP approval. Work performed for the purpose of
• Sidewalk/Curb installation or repair
• Driveway approach installation and repair
SITE INFORMATION • Sanitary/Storm/Water lateral service
Location (address if available): Long: -122.778160 Lat: 45.452964 SEG206 installation and main line tap
• TYPE 3—Work performed with/without
9585 SW WASHINGTON SQUARE RD Tigard 97223 OREGON land use approval which includes any of the
following:
• Subdivisions and Partitions
APPLICANT INFORMATION • Water Infrastructure
Name: Riely Johnson • Street Widening
Mailing address: 1932 Linwood St NW Apt 3088 • Sanitary o r Storm Sewer Infrastructure
97304 • TYPE 4—Small Cell Technology
City/State: Salem OR Zip: • TYPE 5—Tigard Triangle
Phone: 808-457-9321
Email:rielyAnetworkpwrsolutions.co hone: NOTE: Type 1 and 2 applications may be
emailed to rownermitsna tieard-or.¢ov.
Contact name:
Phone: Email:
CONTRACTOR INFORMATION 0 Same as applicant
Name: Pacific Tower Corporation CCB Number: 198050
Mailing address: 1932 Linwood St NW Apt 3088 City/State:Salem OR Zip: 97304
Phone: 808-322-8020 Email: rielyAnetworkpwrsolutions.com
i
ENGINEER INFORMATION
Name:
Mailing address: City/State: Zip:
Phone: Email:
1 ADDITIONAL INFORMATION
Estimated value of work is required(if over$5,000):$ 5.000 (within the public right-of-way)
Is work related to a LAND USE DECISION? 0 Yes I1 No Case number:
City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 1 of4
APPLICANTS
NOTE: Person specified as"Applicant" shall be designated"Permittee"and shall provide financial assurance for
work,if required by the city pursuant to TMC 15.04.140.
* With the exception of a utility operating pursuant to a valid franchise or license with the City of Tigard,when the owner and the applicant
are different people,the applicant must be the purchaser of record or a lessee in possession with written authorization from the owner
or an agent of the owner. The owner 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.
_ Kip Woodrum 10/12/2020
Applicant's or authorized agent's signature Print name Date
Property owner's signature(if required) Print name Date
STAFF USE ONLY
Case No: PFI2020-00385 Permit fee: Received by: SW Date: 10/12/20
Approved by: Date: Notified by: Date:
City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 2 of
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 PH Permit Fee).
WATER LINE CONSTRUCTION FEE
Part 3: All public water system improvements engineer's estimate X 12%.
FOR STAFF USE ON L FOR STAFF USE ONLY
TYPE 4: SMALL WIRELESS FACILITY TYPE 1—3: DETAILED SUBMITTAL
CHECKLIST REQUIREMENTS
Does applicant have a right-of-way license? 0 Yes 0 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): 0 Small Cell 0 Macro ❑ Street Name
❑ Site Address
How many install sites are proposed as part of this permit
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:
0 Public Right-of-Way 0 Private Property ❑ Cover—Site,Vicinity,Abbreviation,Legend
If equipment is to be located on private property,describe the CI General City utility notes/Tigard Conditions of Approval
type&use: ❑ Street(Plan,Profile)
❑ Water,Storm and Sanitary(Plan Profile)
❑ Water Quality Facilities
❑ Grading
FOR STAFF USE ONLY
❑ Landscaping/Tree Plan
CAPITAL PROJECTS CIComposite Utility Plan(Electrical,Phone,Gas, Storm,
Sanitary,Water,Signage,Street Lights,etc.)
❑ Details
El Traffic Sight Distance
Is this a Capital Improvement Project(CIP)? 0 Yes 0 No ❑ Signing and Striping
❑ Street Light Plan and Photometric
Is this permit associated with a Capital Improvement Project ❑ Engineers seal/signature
(CIP)? 0 Yes 0 No El Sheet label(project land use name,revision and plan
log block,dates and sheet numbers.)
PFI permit# _ ❑ Engineer's Construction Estimate
Will this permit require erosion control? Additional Submittals
❑Yes 0 No (per land use conditions,if applicable)
❑ Traffic Report
Blank for future use: ❑ Storm water Drainage Calculations
❑Available Space 0 Available Space ❑ Geotechnical Report
❑ Preliminary Access Report(Sight Distance)
Blank for future use: ❑ Proposed Plat
❑ Pathway Design
❑ Water Provider Approval
City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 3 of4
9 Iv \ I
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TYPE 1 AND TYPE 2:
MINIUM SKETCH REQUIREMENTS (Put N/A if not applicable)
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
City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 4 of
Page 84 2011 Edition
Stationary Lane Closure with Flagging Diagram 320
Diagram 320 covers total closure of one lane of a two-lane, two-way
roadway. See the detail inset for the layout if using a single flagger to control
both directions of traffic on low volume roads (less than 400 ADT)with good
sight distance as discussed below.
1. Use truck-mounted flashing warning lights on work and protection
vehicles. See Section 4.3—Lights and Lighted Signs for exceptions.
2. For added visibility, a truck-mounted arrow board or PCMS in caution
mode may be used.
3. Flaggers at each approach are required if any of the following
conditions exist:
a. Night Operations.
b. Work space is over 200 feet in length.
c. Sight distance is less than 750 feet from each approach
through the lane closure.
d. Traffic volumes are greater than 400 ADT.
4. The length between the Flagger Ahead signs shall not exceed one
mile. Use Diagram 340—Lane Closure with Pilot Car if exceeding one
mile.
5. Cones should be used to outline the work space when curves or other
roadway alignments prevent clear direction for the motorists to pass
the work space safely.
6. Cones along the work space are recommended when posted speeds
are 45 mph or greater, when working under heavy traffic or when travel
lanes are narrower than 11 feet.
7. Extended queue signing (see Diagram 5-4) should be used when
traffic queues extend beyond the initial advance warning sign.
8. When flagging near an intersection, the"Flagger Ahead" (CW23-2)
sign should be visible to traffic entering from any side road. Additional
advance warning and Flagger Ahead symbol signs may be placed on
the side road(s).
9. Sign set-up and flagger placement shown may be used for intermittent
full road closures of 20 minutes or less.
10. The "ONE LANE ROAD AHEAD" (W20-4) sign is optional and should
be considered on high volume or high speed roads, or when extended
queues are expected.
Chapter 5 September 2016
2011 Edition Page 85
Stationary Lane Closure with Flagging Diagram 320
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5iq�p�cing and Buffer Lengths(feet).
Posted Spad3 Between SIMS "Buffer" W
Speed A B C Space Q 0
Ilf
20 50 \ZO:� O
25 100 100 100 75 \
30 100 1
QU 125
350 350 350 150 \
0 45 180 0
50 500 500 500 210 CC
55 250
1 60 285
65 700 700 700 325
70 365
i September 2016 Chapter 5
I
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
_ Request for Permit Action
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ❑X City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
® CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: PF12020-00385
Site Address or Parcel #: SEG 206
Project Name:
Subdivision Name: Lot #:
EXPLANATION: On private property, PFI not requires.
Signature: 4jt .eL " Date: 5/4/2021
Print Name: Ag es indor
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 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 postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to Sys Admin: Date By Route to Records: Date aP./o/Z/ By ./D
Refund Processed: Date A//.4- ByA P Invoice Processed: Date By
Permit Canceled: Date -4,�yi By Parcel Tag Added: Date By
I:\Building\Forms\RegPemvtAction_1:f051 .doc
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City ofTigard WISQ 2d VS ppv PFI#: 2020-00385
6. ENGINEERING DEPARTMENT
TIGARD Public Facilities Improvement (PFI) Permit
_
PROJECT INFORMATION PET 2 (1�'O— d KS
—
TYPE OF WORK
Project name: P029XC053
• TYPE 1—Franchise Utility Work
Brief description of project: Troubleshooting Sprint equipment on performed by NWN,PG , or utility
agency
a cell tower .A manlift is required to reach the equipment.The lift will be • TYPE 2—ROW Sidewalk/Driveway/t,nlin
parked in the road for a couple hours,requiring a TCP approval. Work performed for the purpose of.
• Sidewalk/Curb installation or repair
• Driveway approach installation and repair
SITE INFORMATION • Sanitary/Storm/Water lateral service
Long: -122.778160 Lat: 45.452964 SEG206 installation and main line tap
Location (address if available): • TYPE 3—Work performed with/without
9585 SW WASHINGTON SQUARE RD Tigard 97223 OREGON land use approval which includes any of the
_. following:
• Subdivisions and Partitions
APPLICANT INFORMATION • Water Infrastructure
Name: Riely Johnson • Street Widening
1932 Linwood St NW Apt 3088 • Sanitary or Storm Sewer Infrastructure
Mailing address: p
City/State: Salem OR zip:
97304 • TYPE 4—Small Cell Technology
• TYPE 5—Tigard Triangle
Phone: 808-457-9321
Email:riely@networkpwrsolutions.coPhone: NOTE: Type 1 and 2 applications may be
emailed to rowpermits tt tigard-or.gov.
Contact name:
Phone: Email:
CONTRACTOR INFORMATION ❑ Same as applicant
Name: Pacific Tower Corporation CCB Number: 198050
Mailing address: 1932 Linwood St NW Apt 3088 City/State:Salem OR Zip: 97304
Phone: 808-322-8020 Email: riely(a,networkpwrsolutions.com
ENGINEER INFORMATION
Name:
Mailing address: City/State: Zip:
Phone: Email:
ADDITIONAL INFORMATION
Estimated value of work is required(if over$5,000):$ 5,000 (within the public right-of-way)
Is work related to a LAND USE DECISION? ❑Yes I No Case number:
City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 1 of4
g
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 of Tigard,when the owner and the applicant
are different people,the applicant must be the purchaser of record or a lessee in possession with written authorization from the owner
or an agent of the owner. The owner 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.
Kip Woodrum 10/12/2020
Applicant's or authorized agent's signature Print name Date
Property owner's signature(if required) Print name Date
STAFF USE ONLY
Case No: PFI2020-00385 Permit fee: Received by: SW Date: 10/12/20
Approved by: Date: Notified by: Date:
City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 2 of4
DEVELOPMENT ENGINEERING FEES
Public Facility Improvement(PFI)Permit:
INITIAL PFI PERMIT FEE
Part 1: Required submittal fee is 10%of the Net PH 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 PH Permit Fee).
WATER LINE CONSTRUCTION FEE
Part 3: All public water system improvements engineer's estimate X 12%.
FOR STAFF USE ONLY FOR STAFF USE ONLY
TYPE 4: SMALL WIRELESS FACILITY TYPE 1—3:DETAILED SUBMITTAL_
CHECKLIST REQUIREMENTS
Does applicant have a right-of-way license? ❑Yes 0 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 ❑ 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 City utility notes/Tigard Conditions of Approval
type&use: ❑ Street(Plan,Profile)
❑ Water,Storm and Sanitary(Plan Profile)
❑ Water Quality Facilities
❑ Grading
FOR STAFF USE ONLY ❑ Landscaping/Tree Plan
❑ Composite Utility Plan(Electrical,Phone,Gas, Storm,
CAPITAL PROJECTS
Sanitary,Water,Signage,Street Lights,etc.)
❑ Details
❑ Traffic Sight Distance
Is this a Capital Improvement Project(CIP)? 0 Yes ❑No ❑ Signing and Striping
❑ Street Light Plan and Photometric
Is this permit associated with a Capital Improvement Project ❑ Engineers seal/signature
(CIP)? ❑Yes 0 No ❑ Sheet label(project land use name,revision and plan
log block,dates and sheet numbers.)
PFI permit# 0 Engineer's Construction Estimate
Will this permit require erosion control? AdditionalSubmittals
❑Yes ❑No (per land use conditions,if applicable)
❑ Traffic Report
Blank for future use: ❑ Storm water Drainage Calculations
0 Available Space ElAvailable Space ❑ Geotechnical Report
❑ Preliminary Access Report(Sight Distance)
Blank for future use: ❑ Proposed Plat
❑ Pathway Design
❑ Water Provider Approval
City 0/Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 3of4
CP SW "Y" S 1
Edge of Pavement
do i Ditch
Streetlight —•—•—•—•—•—•—•—r—•—
Rah.Dnai ,..w i
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1 I O groper Line-----
I I —
Fire Hydrant(FM)
I I
Scale: 'I"=30'
I I
I I
I I
i i
TYPE 1 AND TYPE 2:
MINIUM SKETCH REQUIREMENTS (Put N/A if not applicable)
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
City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 4 of4
Page 84 2011 Edition
Stationary Lane Closure with Flagging Diagram 320
Diagram 320 covers total closure of one lane of a two-lane, two-way
roadway. See the detail inset for the layout if using a single flagger to control
both directions of traffic on low volume roads (less than 400 ADT)with good
sight distance as discussed below.
1. Use truck-mounted flashing warning lights on work and protection
vehicles. See Section 4.3—Lights and Lighted Signs for exceptions.
2. For added visibility, a truck-mounted arrow board or PCMS in caution
mode may be used.
3. Flaggers at each approach are required if any of the following
conditions exist:
a. Night Operations.
b. Work space is over 200 feet in length.
c. Sight distance is less than 750 feet from each approach
through the lane closure.
d. Traffic volumes are greater than 400 ADT.
4. The length between the Flagger Ahead signs shall not exceed one
mile. Use Diagram 340— Lane Closure with Pilot Car if exceeding one
mile.
5. Cones should be used to outline the work space when curves or other
roadway alignments prevent clear direction for the motorists to pass
the work space safely.
6. Cones along the work space are recommended when posted speeds
are 45 mph or greater, when working under heavy traffic or when travel
lanes are narrower than 11 feet.
7. Extended queue signing (see Diagram 5-4) should be used when
traffic queues extend beyond the initial advance warning sign.
8. When flagging near an intersection, the"Flagger Ahead" (CW23-2)
sign should be visible to traffic entering from any side road. Additional
advance warning and Flagger Ahead symbol signs may be placed on
the side road(s).
9. Sign set-up and flagger placement shown may be used for intermittent
full road closures of 20 minutes or less.
10. The"ONE LANE ROAD AHEAD" (W20-4) sign is optional and should
be considered on high volume or high speed roads, or when extended
queues are expected.
Chapter 5 September 2016
2011 Edition Page 85
Stationary Lane Closure with Flagging Diagram 320
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11 Sign Spacing and Buffer Lengths(feet), •
Posted Spadng Between Signs "Buffer" W 9 ISpeed A B C Space \, 9a 2 aO
20 50 V ZQ� n
25 100 100 100 75 I `0
30 100
350 350 35040 150 C4pQ]
45 180 0 3 T
50 500 500 500 210 CC
55 250
60 285
65 700 700 700 325
70 365
September 2016 Chapter 5
V
City of Tigard • COMMUNITY DEVELOPMENT DEPARIVONTri
111
NI
Request for Permit ActionI p
,Zj;/�, ,d
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (V):
® CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: PFI2020-00385
Site Address or Parcel#: SEG206
Project Name: Pacific Tower Corporation
Subdivision Name: N/A Lot #: N/A
EXPLANATION: Per Trent Brickey in Engineering, PFI permit is not required because
Washington Square Road is a private street.
10/15/2020
Date:
Signature:
Print Name: Lina Smith
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fcc which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 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 postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to Sys.Amin: Date By Route to Records: Date/L. // Zd By •if
Refund Processed: Date n//LJ— By 0 Invoice Processed: Date By
Permit Canceled: Date By Q Parcel Tag Added: Date By
I:\Boilding\Forms\RerPermitAction_0 _314 oc
v n 1 D ,
City ofTigard 2//// 4PFI#: 2020-00385
II 2 "' ENGINEERING DEPARTMENT
TIGARD Public Facilities Improvement (PFI) Permit
PROJECT INFORMATION
TYPE OF WORK
Project name: P029XC053 • TYPE 1—Franchise Utility Work
Performed by NWN,PGE, or utility
Brief description of project: Troubleshooting Sprint equipment on
agency
a cell tower .A manlift is required to reach the equipment.The lift will be • TYPE 2—ROW Sidewalk/Driveway/Utility
parked in the road for a couple hours,requiring a TCP approval. Work performed for the purpose of
• Sidewalk/Curb installation or repair
• Driveway approach installation and repair
SITE INFORMATION • Sanitary/Storm/Water lateral service
Location (address if available): Long: -122.778160 Lat:45.452964 SEG206 installation and main line tap
• TYPE 3—Work performed with/without
9585 SW WASHINGTON SQUARE RD Tigard 97223 OREGON land use approval which includes any of the
following
• Subdivisions and Partitions
APPLICANT INFORMATION • Water Infrastructure
Name: Riely Johnson • Street Widening
• Sanitary o r Storm Sewer Infrastructure
Mailing address: 1932 Linwood St NW Apt 3088
• TYPE 4—Small Cell Technology
City/State: Salem OR Zip: 97304 • TYPE 5—Tigard Triangle
Phone: 808-457-9321
Email:rielyAnetworkpwrsolutions.coRhone: NOTE: Type 1 and 2 applications may be
emailed to rowpermitsrtigard-or.gov.
Contact name:
Phone: Email:
CONTRACTOR INFORMATION 0 Same as applicant
Name: Pacific Tower Corporation CCB Number: 198050
Mailing address: 1932 Linwood St NW Apt 3088 City/State:Salem OR Zip: 97304
Phone: 808-322-8020 Email: riely@networkpwrsolutions.com
ENGINEER INFORMATION
Name:
Mailing address: City/State: Zip:
Phone: Email:
ADDITIONAL INFORMATION
Estimated value of work is required(if over$5,000):$ 5.000 (within the public right-of-way)
Is work related to a LAND USE DECISION? 0 Yes El No Case number:
City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 1 of4
APPLICANTS
NOTE: Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for
work,if required by the city pursuant to TMC 15.04.140.
* With the exception of a utility operating pursuant to a valid franchise or license with the City of Tigard,when the owner and the applicant
are different people,the applicant must be the purchaser of record or a lessee in possession with written authorization from the owner
or an agent of the owner. The owner 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.
Kip Woodrum • 10/12/2020
Applicant's or authorized agent's signature Print name Date
Property owner's signature (if required) Print name Date
STAFF USE ONLY
Case No: PFI2020-00385 Permit fee: Received by: SW Date: 10/12/20
Approved by: Date: Notified by: Date:
City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www..tigard-or.gov • 303-718-2421 • Page 2 of4
DEVELOPMENT ENGINEERING FEES
Public Facility Improvement(PFI)Permit:
INITIAL PFI PERMIT FEE
Part 1: Required submittal fee is 10%of the Net PH 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 PH Permit Fee).
WATER LINE CONSTRUCTION FEE
Part 3: All public water system improvements engineer's estimate X 12%.
FOR STAFF USE ONLY FOR STAFF USE ONLY
TYPE 4: SMALL WIRELESS FACILITY TYPE 1—3:DETAILED SUBMITTAL
CHECKLIST REQUIREMENTS
Does applicant have a right-of-way license? 0 Yes 0 No TYPE 1 AND TYPE 2-Must include a sketch
showing:
Under the wireless facilities standards,is the proposal 0 Dimensions
considered?(check all that apply): 0 Small Cell 0 Macro ❑ Street Name
0 Site Address
How many install sites are proposed as part of this permit
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:
0 Public Right-of-Way 0 Private Property ❑ Cover—Site,Vicinity,Abbreviation,Legend
If equipment is to be located on private property,describe the ID General City utility notes/Tigard Conditions of Approval
type&use: ❑ Street(Plan,Profile)
❑ Water,Storm and Sanitary(Plan Profile)
❑ Water Quality Facilities
❑ Grading
FOR STAFF USE ONLY ❑ Landscaping/Tree Plan
❑ Composite Utility Plan(Electrical,Phone,Gas, Storm,
CAPITAL PROJECTSSanitary,Water,Signage,Street Lights,etc.)
❑ Details
❑ Traffic Sight Distance
Is this a Capital Improvement Project(CIP)? 0 Yes ❑No 0 Signing and Striping
O Street Light Plan and Photometric
Is this permit associated with a Capital Improvement Project 0 Engineers seal/signature
(CIP)? 0 Yes 0 No ❑ Sheet label(project land use name,revision and plan
log block,dates and sheet numbers.)
PFI permit# ❑ Engineer's Construction Estimate
Will this permit require erosion control? Additional Submittals
❑Yes 0 No (per land use conditions,if applicable)
O Traffic Report
Blank for future use: 0 Storm water Drainage Calculations
❑Available Space 0 Available Space ❑ Geotechnical Report
❑ Preliminary Access Report(Sight Distance)
Blank for future use: 0 Proposed Plat
❑ Pathway Design
O Water Provider Approval
City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 3 of4
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TYPE 1 AND TYPE 2:
MI IUM SKETCH REQUIREMENTS (Put N/A if not applicable)
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
City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 4 of
Page 84 2011 Edition
Stationary Lane Closure with Flagging Diagram 320
Diagram 320 covers total closure of one lane of a two-lane, two-way
roadway. See the detail inset for the layout if using a single flagger to control
both directions of traffic on low volume roads (less than 400 ADT)with good
sight distance as discussed below.
1. Use truck-mounted flashing warning lights on work and protection
vehicles. See Section 4.3—Lights and Lighted Signs for exceptions.
2. For added visibility, a truck-mounted arrow board or PCMS in caution
mode may be used.
3. Flaggers at each approach are required if any of the following
conditions exist:
a. Night Operations.
b. Work space is over 200 feet in length.
c. Sight distance is less than 750 feet from each approach
through the lane closure.
d. Traffic volumes are greater than 400 ADT.
4. The length between the Flagger Ahead signs shall not exceed one
mile. Use Diagram 340—Lane Closure with Pilot Car if exceeding one
mile.
5. Cones should be used to outline the work space when curves or other
roadway alignments prevent clear direction for the motorists to pass
the work space safely.
6. Cones along the work space are recommended when posted speeds
are 45 mph or greater, when working under heavy traffic or when travel
lanes are narrower than 11 feet.
7. Extended queue signing (see Diagram 5-4) should be used when
traffic queues extend beyond the initial advance warning sign.
8. When flagging near an intersection, the"Flagger Ahead" (CW23-2)
sign should be visible to traffic entering from any side road. Additional
advance warning and Flagger Ahead symbol signs may be placed on
the side road(s).
9. Sign set-up and flagger placement shown may be used for intermittent
full road closures of 20 minutes or less.
10. The"ONE LANE ROAD AHEAD" (W20-4) sign is optional and should
be considered on high volume or high speed roads, or when extended
queues are expected.
Chapter 5 September 2016
2011 Edition Page 85
Stationary Lane Closure with Flagging Diagram 320
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Sign Spacing and Buffer Lengths(feet) I + V
Posted Spedng Between Signs "Buffer" W;1.12Speed A B C Space \ 0
20 50 ¢
25 100 100 100 75 I v ...
_30 100
350 350 35040 150 Y
45 180 It
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50 500 500 500 210 2
55 250
60 285
65 700 700 700 325
70 365
September 2016 Chapter 5