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PFI2021-00038 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT s COMMUNITY DEVELOPMENT Permit#: PFI2021-00038 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 06/08/2021 Parcel: 1 S 1356600500 Jurisdiction: Tigard Site address: 10487 SW CASCADE AVE Subdivision: None Lot: None Project: SQF, LLC Project Description: New freestanding small cell wireless facility located at 10487 SW Cascade Ave. Class of Work: FEES Description Date Amount Type 4-Small Cell Wireless Facility PFI Permit Fee 03/02/2021 $300.00 Additional Plan Review(minimum charge 03/02/2021 $270.00 Owner: 112 hour) Total $570.00 PHONE: REQUIRED INSPECTIONS Call 503-639-4175 for the IVR inspection request line or visit the City of Tigard website at www.tigard-or.gov to schedule inspections online. Contractor: TILSON TECHNOLOGY MANAGEMENT INC 16 MIDDLE ST 4TH FLOOR PORTLAND, ME 04101 PHONE: 2075916427 Applicant: NICHOLAS BOURNAKEL 16 MIDDLE STREET 4TH FLOOR PORTLAND, ME 04101 PHONE: 2076710893 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: I&M &4 L1--J Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12021-00038 Type: Condition Name: Status: Severity: PFI—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 19-PRECONSTRUCTION MEETING Applied Notice Before initiating any construction activity,the applicant shall coordinate with the City's inspector, <Insert Name>at<Insert Phone#>,to establish a preconstruction meeting. PFI—Small Cell 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—Small Cell 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—Small Cell 22-DAILY INSPECTION REPORTS Applied Notice Applicant shall submit daily inspection reports, on a weekly basis, to the City's Inspector. PFI—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 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—Small Cell 31 -OTHER Applied Notice Other City of Tigard PFI #: 2 0 2/ ENGINEERING DEPARTMENT Public Facilities Improvement (PFI) Permit For use by Utility Providers (Small Cell) PROJECT INFORMATION TYPE OF WORK Project name: SQF,LLC—Tigard Small Cell Wireless Facilities ® TYPE 1 —Small Cell Technology Node Description of project: See attached Project Description Installation ❑TYPE 4—Utility energization performed by PGE or utility agency What utility services will the facilities provision? PERMITTING - APPLICANT SHALL. See attached Project Description Apply for&obtain PFI Permit.Pay all required fees. SITE INFORMATION Permit will be issued to applicant by City staff and Location (address if available): Across the street from 10487 SW will expire after 90 days. Cascade Ave. se^ 44(p INSPECTION - CONTRACTOR SHALL Notify within 5 days of APPLICANT INFORMATION (Service Provider) beginninginstallation. Name: _ SQF,LLC Notify rowpcnnirs@;tigard-or.gov,within 5 days of completion of installation. Mailing address: 16 Middle Street, 4` Floor Notify rowpermits a ti}rard-or.Gov,5 days before City/State: Portland, ME Zip: 04101 connecting or energizing facilities. Phone: (207)671-0893 Contractor must call 503-639-4175 to schedule inspections before 7 a.m.(at the latest)on the Email: nbournakel@tilsontech.com phone: (207)671-0893 of inspection.Use code 738 Contact name: Nicholas Bournakel Phone: (207)671-0893 Email: nbournakel@tilsontech.com ROW License Number: 2020-00039 CONTRACTOR INFORMATION ❑ Same as applicant Name: Tilson Technology Management, Inc. CCB Number: 212930 Mailing address: 16 Middle Street,4th FloorCity/State: Portland, ME Zip: 04101 Phone: (207)591-6427 Email: prolicensing@tilsontech.com City Business License Number: 02519 (This is SQF's business license#.Tilson is an affiliate of SQF.) ENGINEER INFORMATION Name: Emad Badiee,Tilson Technology Management, Inc. Mailing address: 16 Middle Street,4' Floor City/State: Portland, ME Zip: 04101 Phone: (404)480-5555 Email: ebadiee@tilsontech.com City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 1 ADDITIONAL INFORMATION Estimated value of work:$ $14,500 (does not include the cost to run power and does not include any 4G/5G equipment. Is work related to a LAND USE DECISION? ❑ Yes N No Land Use Case number: 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. 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. Applicant and Contractor acknowledge receipt of all the City's regulations and TMC and agree to abide by all regulations contained therein. Application and Contractor acknowledge receipt and agree to abide by the permitting process and all other City of Tigard regulations listed on this application. I hereby certify,on behalf of Applicant,that to the best of my knowledge and belief this information is true and correct as of the date hereof. Licensee agrees to comply with the provisions in the Tigard Municipal Code, including,but not limited to Chapter 15.06. By executing this application, the undersigned affirms that she/he is an authorized representative of the Applicant with the authority to execute the application and bind applicant to all provisions of the Tigard Municipal Code c✓cam C• �Y � Nicholas Bournakel 1/22/2021 Applicant's or authorized agent's signature Print name Date Property owner's signature (if required) Print name Date STAFF USE ONLY PFI No: 2192f —100010 Permit fee: O0 Received by: 67 Date: Approved by: r Date: f0/7 Z/ Notified by: AL, Date -1 City of Tigard 13125 SW Hall Blvd. Tigard,Oregon 97223 • www.dgard-or.gov 503-718-2421 2 DEVELOPMENT ENGINEERING FEES All Public Facility Improvement(jFI)Permit fees due upfront 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 calculated from engineer's estimate x 7% (less the initial PFI Permit Fee). FOR • TYPE 1 PFI: SMALL WIRELESS TYPE 4 PFI: CHECKLIST FACILITY CHECKLIST NOTE:Applicant must have a ROW License with Is all applicable small cell equipment installed? the City of Tigard prior to applying for the PFI (Check box) Does applicant have a right-of-way license? (Check box) ❑Yes I] No ® Yes ❑No Date of Completion: ROW License Number: 2020-00039 Contractor must provide photos of the location of the Small cell installation site from all angles: (N,S,E,W) Under the wireless facilities standards,is the proposal considered?(check all that apply) E Small Cell ❑Macro How many install sites are proposed as part of this permit application? 1 The proposed equipment is located on which of the following: (Check box) ® Public Right-of-Way ❑ Private Property If equipment is to be located on private property, describe the type&use: Who will be using the facilities to provision services? Wireless cellular companies for siting small cell antennas. Will the facilities allow other providers to use capacity?--Yes City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 wwwtigard-or.gov 503-718-2421 3 sw "Y" St Edge of Pavement f— Ditch ---- ► Streetlight 1 —•—•—•—•—•—•— —�—•— ° Ram Draft, I 1 rTe" I 1 0� I fr "r 1 ry I ! Existing House Q I 1 Existing >r • Driveway . 1() al tI � � 1 1 O Existing Shop Powerpole I I la 95' 1 O 'lsiopert Line A Fire Hytlrant(FH) I I I 1 Scale: 'I"=30' I 1 I TYPE I AND TYPE 4 PH MINIMUM SKETCH REQUIREMENTS (Put N/A if not I I I ' I I I applicable) North arro\c 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 of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.6gard-or.gov a 503-718-2421 4 co�smmxroN I wMmc SQF , LLCSQFF,L LLC SITE NAME: SQFCH—CON1003_TIGARDOR 06 Co M= C,Moa,, PROPOSED WI—FI SMALL CELL NODE_ PwErurto m 10429 SOUTHWEST CASCADE AVENUE T I L S O N TIGARD, OR 97223 or a Mission WASHINGTON COUNTY51R '"""m EaTLND. WE"101 LAT:45°26'44.69" (N)/45.445747' T(TR7)%1-w LONG:122°46'55.83"(W)/-122.782175° �� �mIX V SW WaznmgL PROJECT LOCATION] • REVISION HISTORY. eYDH� W 1 b4A0 ipi PFRMi tEH n d Q 217 2W o mo m n - •2. .«.- 6 - nmrtr vara SATELLITE IMAGE STREET MAP SITE NAME: SOFCH-CONIOD3-TIGARD_OR_06 PROJECT SUMMARY PROJECT INFORMATION SHEET INDEX THE PURPOSE OF THIS DOCUMENT IS TO PROVIDE SITE NAME: wrcN-CON1003-71wro-0R-06 9ay 10429 SOUTHWEST CASCAD GENERAL INFORMATION IN REGARDS TO LOCATION AND ll ® AVENUE SIZE OF THE PROPOSED WI-FI SMALL CELL EQUIPMENT SITE ADDRESS: 10429 SOUTHWEST CASCADE AVENUE T-I nnE Mm TIGARD, OR 97223 ARRANGEMENT. THIS DOCUMENT IS ISSUED FOR TIGARD,OR 97223 WASHINGTON COUNTYPERMOTRIG PURPOSES ONLY,AND SHALL NOT BE USED 01-1M]FML MCTFS FOR CONSTRUCTION. STNICIIAIE GMMER: SOF.UL CD-2 PINPOEED WORE ladTM EVM LOCAL UTIUTY CONTACTS s[rt M POLE NUMBER: 2.174 �a ENIII®XORE lfYA110N%M ELECTRIC UTILITY: PGE SE/A10E ELE TELEPHONE ONE-FRONTIER �• Pal£ TITLE SHEET PHONE: (503) 771-3817 APPUCWr: SOF.LLC CD-6 PolE a10111pIG AM/HIaC TELEPHONE COMPANY: FRONTIER ROM OWNER MUNICIPAL NE EaANE1R RTMS pua-. rtM «[E',q PEV PHONE: (800)-921-8106 STRUCTURE TYPE: PROPOSED MTEgU1ED POLE T-1 A !RaAorT EF cowlRuclvE IMuww PRFnueFD roR. SQF, LLC cox61W¢7Dx IRE7WIW PICPMm�, GENERAL NOTES: 1. ML "ecraw TRIM Rftl WM)N HQIEN A LCILm,LL r ENGMER FBI 91TFACE EMENCE MD PUM m RECORD TIL 5 0 N ML 111OpgIPRD IRUIES sxpAD B[Locvm N M dEiL'rr co,T ,-v nBnR ro d71IQORIRD a RL snE IORC caxlRx�oR flWL CAL OKM B WMN nE n HOURS PRIOR TO HMNco CDXSI I*N xCIMrv. :J rt a Mi 5`.i on 2. W 60RR S1 BE COI D CQRPKIpI x IOOO)RT ItE WIM Ill WIpiINFS MD RE(iRArDNS D TRIO N April VERWI 16 1111,011 SIREEF, FTH FLOOR, FNIRBIIED BY EINGRFm. POR(M7) Irt ME01 S. 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