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PFI2021-00108 L CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT = COMMUNITY DEVELOPMENT Permit#: PF12021-00108 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Data Issued: 04/15/2021 Parcel: 2S 112BD03000 Jurisdiction: Tigard Site address: 7929 SW MARA CT Subdivision: MARA WOODS Lot: 1 Project: J5 Infrastructure 022/20590-007 Project Description: Replacement of existing metal light pole with metal light pole integrated with small wireless facility Class of Work: FEES Type 4-Small Cell Wireless Facility Description Date Amount PFI Permit Fee 04/13/2021 $300.00 Additional Plan Review(minimum charge 04/13/2021 $405.00 Owner: 1/2 hour) Total $705.00 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: PHONE: Applicant: KRISTY WEAVER 19801 SW 72ND AVE TUALATIN,OR 97062 PHONE:4252142186 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. PermitteelApplicant Signature: see application Issued By: c. Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12021-00108 Tvoe: 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 pennit. 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 Ceti 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 comers, 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 anylall 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#: P- 1202) -oo/o e ENGINEERING DEPARTMENT Public Facilities Improvement (PFI) Permit PROJECT INFORMATION TYPE OF WORK Project name: TGARD_022/20590-007 ❑ TYPE t-Franchise utility Work Brief description of project: Replacement of existing metal light pole agency aby vW1v.Pcl, orntiliro agency with metal light pole integrated with small wireless facility ❑ TYPE 2-ROW SidLwalk/Driveway/sewer Work performed for the purpose of • Sidewalk installation or repair • Driveway approach installation and repair SITE INFORMATION • Sanitary-sewer lateral installation and main lute tap Location (address if available): 7929 SW Mara Ct ❑ TYPE 3—Dull Scale Development\`('cnk performed with land use approval which includes any of the following: • Subdivisions or Partitions APPLICANT INFORMATION • Street widening Name: New Cingular Wireless PCS, LLC (AT&T) • )Sautline instauat"° for "rri`arI storm sewer, 'Tigard water, and 'Tigard Mailing address: 19801 SW 72nd Ave water scriice area City/State: Tualatin, OR Zip: 97062 ® TYPE 4-Small CellTcchnolo��, ® TYPE 5—Tigard Triangle Phone: 425-214-2186 Email: ko3199 att.eom Phone: 425-214-2186 NOTE: Type ype 1 and 2 applications may be Contact name: Kristy Weaver emailed to rowpermits@heard-or.gov. Phone: 425-214-2186 Email: ko3199@att.com CONTRACTOR INFORMATION ❑ Same as applicant Name: Capstone Solutions Inc CCB Number: 196584 Mailing address: 13126 NE Airport Way, Suite 100 City/State: Portland, OR Zip: 97230 Phone: 503-707-2656 Email: cblack@capstoneemail.com ENGINEER INFORMATION Name: J5 Infrastructure Partners Mailing address: 6732 SW Terri Ct City/State: Portland, OR Zip: 97225 Phone: 503-312-3400 Ems: mhewett@j5ip.com ADDITIONAL INFORMATION Estimated value of work is required(if over$5,000):$ 14,000.00 (within the public right-of-wag) Is work related to a LAND USE DECISION? ❑Yes M No Case number: Cityof Tigard • 13125 SW Mall Blvd. • Tigard,Oregon 97223 • www:tigard-orgov • 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 TNTC 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 appfication is granted, I will exercise the rights granted in accordance with the terms and subject to all the conditions and limitations of the approval. M. / 1wAJ# Meredith T. M. Hewett 03/26/21 A plicant's or authorized agent's signature Print name Date Property owners signature (if required) Print name Date STAFF USE ONLY Case No: 10)c:Z V--d61Ae Permit fee: � 7OS Dd Received bv: Date: 3 Z�Z Approved by: a ,t4 Date: `t/I y/ / Notified by:�Date: 5 City of Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtiganl-or.gov • 503-718-212] 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 ONLY • ONLY TYPE 4: SMALL WIRELESS FACILITY TYPE 1-3:DETAILED SUBMITTAL CHECKLIST REQUIREMENTS 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 F-1 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,re,6sion 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-orgov • 503-718-2421 • Page 3 of 4 Edge of Pavement I -0- - Ditch Streetlight Pu nn ' aT - ooF(MC4 1 I ti l 1 Existing House Existing 1 Dmeway �I a� yI Un A I � Extsbng Shop �~ Ppwerpno 95, 1 I �—•-------'Pioperty'Lme---------- I 1 I Scale: 1-=30' I 1 I TYPE 1 AND TYPE 2: MINIUM SKETCH REQUIREMENTS (Put N/A if I I ! � I I � i I 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 of Tigard • 13125 SVX'l lall Blvd. • Tigard,Oregon 97223 - wwwtigatd-or.gov • 503-718-2421 - Page 4 of 4