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PFI2022-00017 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12022-00017 Date Issued: 01/18/2022 • 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Parcel: 2S110ABO1700 Jurisdiction: Tigard Site address: 14220 SW 114TH AVE Subdivision: COLE'S ACRES Lot: 4 Project: Black Rock Underground Pipe Replacement Project Description: pipe burst; replace culvert in front of home, approx. 100'of 10" HDPE pipe Class of Work: FEES Type 2-Sidewalk/Driveway Approach 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 at www.tigard-or.goy to schedule inspections online. Contractor: PHONE: Applicant: CORY MOORE PO BOX 5999 BEAVERTON, OR 97006 PHONE: 5037479312 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: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12022-00017 Type: Condition Name: Status: Severity: PFI_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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—Sidewalk/1 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—Sidewalk/1 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalkl[ 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_Sidewalk/[ 18-SEWER SYSTEM TEST Applied Notice A sewer system air-test and/or DVD T.V.test report and one set of"As-Builts"shall be provided for review and approval. PFI_Sidewalkl[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 22-DAILY INSPECTION REPORTS Applied Notice Applicant shall submit daily inspection reports, on a weekly basis,to the City's Inspector. PFI_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalk/[ 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_Sidewalkl[ 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_Sidewalk/[ 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_Sidewalk/[ 31 -OTHER Applied Notice Other City of Tigard ltl l ,r;_ 2022-00017 it FNGINFERING D1-TART,\I1:NT Public Facilities Improvement (PFI) Permit PROJECT INFORMATION '1'1'1'1:OF WORK Project name: G.1 TYPE' I - kanchi�14 hn %1" Ixrtimticd h+ 5111,P(il{, ur utiGtt Brief descnpiton of projecrO ►Tg, ��t S e,b\a ✓e, c.ulvcr'� to t D TYPE <Ec fpp //�� ( �T kko k perlirt mal file the pori 4 Q 10' AV INi tT� • SithmAlk inmAUtilm or rgwr • Dmvm Av aprmarh inw►llannn and rerxr SITE INFORMATION • Sanitan•seuetlateralin%ratlarun and SW �`l�' main!uu rap Lc>cati<in {addresc if sivailablc): t dt �` U Tt'PE3-Full Srak lh-.ctt>rtrlcnr \Y++rk triAC1t<' ` ft performed M Ith land me algxt v.-4 tt'hirh Q inrlucicr.any of the futlmvin}t: • N;Arctivitismst.l Pattitiom APPLICANT INFORMATION titrttt widcnitly `A`1 _ C 14AMI u inr, Tspm til' s. an carr, Name: Vrb- {�.PV q Q�.�����. euiml xww7, 'Ci�lrel ama�lr. ark) Tel;aeel Mailing addrC::S: f � TJOX �� 1 1 tinter rcn-itt arca : 9'i oot, I VI(PH 4—SHIA Cr11'I tvhrN,1,j Nj (:itv/State: ltayed'tori 0� Gip l.; TYPE,5-'I'sgmiTting1c Phone: Finail: xi Phone: NOTE: T}pc I Itnd 2 applications may Ix Ix Contact name: Cor15 "lty�`1 o o C pr t'nl filled fry-+ti+-K-rn r..,F�i ilC>���Lk!a1. Phone: so-3.`? -t1 .931� cmad: in @baaC'V- f- s Y\a cora CONTRACTOR INFORMATION IR Same as applicant Name: CCB Ntnubcr: 101 (D 1 1 9 Mailing addreas: Cite/Stntc: Phone: I imaii: ENGINEER INFORMATION Name: Mailing address: City/State: Gip: Phone: Ismail: ADDITIONAL INFORMATION Iistimatcd value of cork is rrquirul(if uvcr S,lkNi):S N q (within the public right-tlf-u an) Is work- related to a LkNI) USF: DI:CISI(.)N% ❑Yes ❑No Case number: City pf Tigard • 13125 SW I lall Blvd. • 'I 19art1,t)rrgtm 97223 - vnvwtigard-ur.gov • 303-718.2421 - Page 1 of 4 APPLICANTS NOTE: Person specified as"Applicant"shall he designated"Permittee"and shall prtwitic financial assurance for work,if reyaired by the citV pursuant to TMC 1 S.tlA.14u. With div v\ctpmin of a oulm t lxranng rd r+uanr at a t-alkl fmnchiu or linnw u irh the<'tq.of Ttlpril.trhen the„user and rhe applicant arc diffcrcm ptuph,the applicam mum he the purcltx-T of rcrnnl ur u"see in ptr.e�sion With wriucn xuth<mzation from the[AwmT of an agem ui the owner. 11w uHmcr most sign this appftcattuo to the%Paec Pn„RIL4 or o-ubnrit a urincn aude,rirauun n ith tlnx applicutuaf. 1-ranchiuxt or 13ccmvt1 Uihoci arc n•x mquir.Yl tit oht+in dw tn+•ncr a sitmaturc tm the application. I, the applicant,certify Char. • To the best of my knowledge,all the infomlation provided within this application package is complete and accurate. • The above request does not violate any retarded decd resttictions that may be attached to or imposed upon the subject propcm. • If the application is granted, l will exercise the rights granted in accordance with the terms and subject to all the conditions and limitations of the approval. Is OU". 1phlic5m t tr .luthnWiW. agent's signature Imirilit n:utti Vr�ft�tro� �4LG C):uc property t,wner's signature (if required) 1'1.;111 namt 1).11U Case No: PF12022-00017 Permit fee: Received i,,: SPV pate: 1/18/2022 Approved hv: LJ , SA etc Datc: l0 •21zL�1, Norificd by: �— _ Date: j$ 2e�22 City Of Tigard 1112; S%\ 11.111 Mid. • 'I'lg:tnl,()rcg%m' '.' uwuaal{ani-uaKtty 54t3418.1.121 • Pagc 2 oJ'4 DEVELOPMENT ENGINEERING FEES Public Facility Improvement (PFI) Permit: TNTTIAI.PFI PERMIT FEE Part I: Rcgturetl submittal fee is I .of the Net Phl Permit Pte.Sec helow for calculation!..Minimum of 5300, NET PFI PERMIT FEE Part 2: All non-watcr system imp"wements criOncer s estimate X 77,r(Icsc the initial PPI Permit I.cc), WATER I.INE CONSTRUCTION FEE Pan 3: All Public ureter Astem improvements en(;inctY's estimate X FOR STAIFF USE ONLY DETAILEDTYPE 4:SMALL WIRELESS FACILITY IYPE 1—3: SUBMITTAL CHECKLIST 13ocs applicant hat, .t fig it t,t ,,.t% ixn,." G 1" J \t, TYPE I AND"TYPE 2-Must include a sketch showing: Under the wirck-ss facilities swndanls,is tie proposal ❑ Dimensions considered?(Check all that apply): ❑Small Ccll ❑ \Macro ❑ Street Namc flow many install sites arc proposed as pan of this pcmtit L7 Site Atklress application? TYPE 3- Must provide 4 seta of plans(sized 24 x 36 or 22 x 34) and an electronic version of all sohmirt:tl The propoicd equiprrxm is locarecl on which of the following: items, The plans must that include: ❑Public Right-of-Way ❑Private Proper! ❑ (:Dutyr—Site,Yicintts,:\bbrrviatitin,Ifigcnd If equipment is it)be located un private property,describe the ❑ Gencrd Nntcs(City.C(atrr,Scacr,ctc.) type ttt use: ❑ Strcct(Plan,Profile) ❑ Water.Storm and Sanitary(Plan P"file) ❑ \V'21erQU2l tl'facilities ❑ Grath!!, ❑ I-vWscapinp/Trcc Plan ❑ Crmtpositc I*Hlity Plan(Hecrrical,Phone,(las, Storm, Sanitary,\Vater,SigMgC.Street I.iglus,rm) ❑ lhtails 1'raffic Sight Distance ❑ Signing and Striping Cl Street light Plan and Photometric ❑ I�nginccnscal/signature ❑ Shut label(proicet land use nano•,revision and plan Ing block,bates and sheet numbers.) ❑ fnginccr's Gmstruction Ustimati; Additional Submittals (per land uw conditions,if applicable) ❑ Traffic Report ❑ Storm water Drainage Calculations ❑ Geotechnical Repo" ❑ Prelinunars Access Rcport(Sig(u I)istanccl ❑ Proposed PUI ❑ Pathwa\ Dcagn ❑ \1'atcr Ptvridc•r Ipprotial City of Tigard t ;j?;til\ l i:dl Itl ti • 'I ir.o,l, i tt<:;.,n y" ,c,.ca.t;4.it+1 „t. ;t ;r "IV =11i I'aXe.3 of 4 Location: ;�� , o� Name: Date: e. Point of Access: Pipe Type: %X � n Depth At Home: F �ss �a'q lean Depth at Curb: Depth At Main: Machine Access: Y N Roots Q Pooling d Off-Sets Cracks r4 Repair Type: Y>vf 0 cs Length of Repair: oo' f Notes: