PFI2021-00238 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
= COMMUNITY DEVELOPMENT Permit#: PFI2021-00238
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 07/08/2021
Parcel: SEG3475
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: PGE Job#M2994998
Project Description: Install underground service to home, install pole conduit,and transformer. Removed temp services.
Conduit provided and installed by customer.
Class of Work: FEES
Type 1 -Utilities(gas,electric, data) Description Date Amount
PFI Permit Fee 07/07/2021 $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.tigard-or.00v to schedule inspections online.
Contractor:
PHONE:
Applicant:
JOSE VELASCO
4245 KALE ST NE
SALEM, OR 97305
PHONE: 5036725454
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 permit application
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
h
Conditions for PF12021-00238
Type: 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, <Insert Name>at<Insert
Phone#>,to establish a preconstruction meeting.
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.
Contact Ken Fisher at 503 816 6146 or kenny@tigard-or.gov
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 comers, and survey markers shall be protected. Replacement shall be at the permit holder's
expense.
PFI_Utilities 24-VALIDATION OF MATERIALICONSTRUCTION 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
RECEIVED
City of Tigard JUN 2 3 2021 PFI#: .2p2� bQ23�
ENGINEERING DEPARTMENT CITY OF TIWD
Public Facilities �'.�`ove iiNit (PFI) Permit
PROJECT INFORMATION
PGE Job # M2994998 TYPE OF WORK
Project name: 8 TYPE I—Franchise Utility Work
Brief description of project•. Install underground service to home, performed by NWN,PGE, or utility
agency
install pole conduit and transformer. Removed temp services. ❑ TYPE 2—ROW Sidewalk/Driveway/Sewer
Conduit provided and installed by customer. Work performed for the purpose of.
Sidewalk installation or repair
• Driveway approach installation and repair
SITE INFORMATION Sanitary sewer lateral installation and
9677 SW 74th Ave, Tigard main line tap
Location (address if available): g
❑ TYPE 3—Full Scale Development Work
,? performed with land use approval which
includes any of the following:
• Subdivisions or Partitions
APPLICANT INFORMATION • Streetwidening
Name: PGE Briana Fogh b[ainlute installation for sanitary sewer,
storm sewer, Tigard water, and Tigard
Mailing address: 4245 Kale St NE water service area
City/State: Salem Zip: 97305 ❑ TYPE 4—Small Cell Technology
Phone:
503.672.5454 ❑ TYPE 5—Tigard Triangle
Email: briana.fogh@pgn.eom Phone: 503.672.5454 NOTE: Type 1 and 2 applications may be
Contact name:
Jose Velasco emailed to rowpermitgatigard-or.gov.
Phone: 503.672.5454 Email: jose.velasco@pgn.com
CONTRACTOR INFORMATION 0 Same as applicant
Name: CCB Number:
Mailing address: City/State: Zip:
Phone: Email:
ENGINEER INFORMATION
Name: Jose Velasco
Mailing address: 4245 Kale St NE City/State: Salem Zip: 97305
Phone: 503.672.5454 Email: jose.velaseo@pgn.eom
ADDITIONAL INFORMATION
Estimated value of workis required(if over$5,000):$ (within the public right-of-way)
Is work related to a LAND USE DECISION? ❑Yes 0 No Case number:
Cityof Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 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 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. 1'he 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.
Briana Fogh 6123/2021
Applicant's or authorized agent's signature Print name Date
Property owner's signature(if required) Print name Date
STAFF USE ONLY
Case No: � Arnit fee: ;''' •� _ Received by: ,p.� Date: �-/
Approved by:1<. /fritt._ Date: 7-7-7-02-t Notified by: All l Date: -7 ? 24
Cityof Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 0 www.fgard-or.gov • 503-718-2421 • Page 2 of 4
DEVELOPMENT ENGINEERING FEES
Public Facility Improvement(PFI)Permit:
INITIAL PFI PERMIT FEE
Part 1: Required submittal fee is 101/o 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 • ' STAFF USE ONLY
TYPE 4: SMALL WIRELESS FACILITY TYPE 1-3:DETAILED SUBMITTAL
REQUIREMENTSCHECKLIST
Does applicant have a right-of-way license? ❑Yes ❑N„ 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
Mow many install sites are proposed as part of this permit [I 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,revision 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
Cityof Tigard 13125 SW Hall Blvd. Tigard,Oregon 97223 • www.fgard-orgov • 503-718-2421 • Page3 of 4
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MINIUM SKETCH REQUIREMENTS (Put N/A it'nol �tI)IfliC,11)IL-)
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(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
Cityof Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-orgcv • 503-718-2421 • Page 4 of 4
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RIGHT-OF-WAY PERMIT NOTICE'
A PERMIT FROM THE LOCAL JUNIGGRO ON IS REQUIRED BEFORE ANY
3' 15663 WORK N THE RKiHT-0F-WAY NN Y BE PERFORMED. ONLY FT;APPROVED
CONTRACTORS AND CONTRACTORS WHO HAVE MADE OTHER SPECIAL
CONDUIT 2M AGREEMENTS WITH PGE WILL BE ALLOWED TO WORK UNDER PGE1 PERMIT
THE CONTRACTOR MUST NOTIFY THE LOCAL XR13DKTION 43 HOURS
EFFORT WEAN IS TO BI A COPY OF THE FERMI MLIST RE ON SITE.
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OREGON LKW REWIRES YOU TO FOLLOW RULES ADOPTED 96TT SW 74TH AVE M77 TIGARD OR 97223
THINK BY THE OREGON UTILITY NOTFICAl10N CEMER. ` DESCRIPTION
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Page 118 2011 Edition
Lane Closure at Intersection with Flagging Diagram 620
Diagram 620 covers work within an intersection when normal traffic control
must be interrupted. Work vehicles may or may not be in the work space.
1. During flagging, traffic signals shall be turned off. Contact the road
jurisdiction for approval and assistance (see Chapter 3).
2. For multi-lane facilities, traffic approaching the intersection shall be
reduced to a single lane on each approach. See Chapter 3 for
information on flagging through intersections.
3. There should be one flagger for each approach. One flagger may
control two adjacent approaches if sight distance, low volumes on side
roads, and flagger position allows for safe operation and clear direction
to motorists. For low traffic volume intersections (fewer than 400
entering vehicles per day), one flagger may be used.
4. 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 may be expected.
Sign Spacing and Buffer Lengths(feet)
Posted Spedng Between Sigro "Buffer"
Speed A B I C Space
20 50
25 100 100 100 75
30 100
35 350 350 3S0 125
40 ISO
45 150
50 S00 S00 500 210
55 2S0
60 285
65 700 700 700 325
70 365
Chapter 5 September 2016
2011 Edition Page 119
Lane Closure at Intersection with Flagging Diagram 620
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September 2016 Chapter 5