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PFI2022-00187 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT # COMMUNITY DEVELOPMENT Permit#: PFI2022-00187 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 05/05/2022Parcel: SEG631 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: PGE#M3098671 Project Description: PMO 07-2020 OH Fitness- Replace B/O Foreign PL#5872. SEG 631 Class of Work: FEES Type 1 -Utilities (gas, electric, data) Description Date Amount PFI Permit Fee 05/05/2022 $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.gov to schedule inspections online. Contractor: PHONE: Applicant: ELEASA ANDERSON 10800 SE AVERY ST TUALATIN, OR 97062 PHONE: 5036126194 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. PermitteelAppl!cant See application Signature: Hope Pollard Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12022-00187 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. 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 corners, and survey markers shall be protected. Replacement shall be at the permit holder's expense. PFI_Utilities 24-VALIDATION OF MATE RIAUCONSTRUCTION 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 engineers certification of installation compliance (Certificate of Compliance). PFI—Utilities 31 -OTHER Applied Notice Other City of Tigard PFI#: 2022-00187 C ENGINEERING DEPARTMENT . Public Facilities Improvement (PFI) Permit PROJECT INFORMATION TYPE OF WORK Project name: PGE Job # M3098671 R TYPE I—Franchise Utility Work Brief description of project: _ performed by NWN,PGF:, or utility agency PMO 07-2020 OH FITNES - REPLACE B/O FORIEGN PL # 5872 ❑ TYPE2—ROWSidewalk/Driveway/Sewer SEG 631 Work performed for the purpose of. • Sidewalk installation or repair • Driveway approach installation and repair SITE INFORMATION • Sanitary sewer lateral installation and 11200 SE Tigard St. Tigard, mamhnetap Location (address if available): g g d, OR ❑ 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 Nance Stone/Eleasa Anderson • Mainline installation for sanitary sewer, storm sewer, Tigard water, and Tigard Mailing address: 10800 SE Avery St water service area City/State: Tualatin, OR Zip: 97062 ❑ TYPE 4—Small Cell Technology Phone: 503-612-6194 ❑ TYPE 5—Tigard Triangle Email: Contractor-Coordination@pgn.com phone: 503-464-7777 NOTE: Type 1 and 2 applications may be Contact name: Eleasa Anderson emailed to rowpermitc 1iWd-oL.gov. Phone: 503-612-6194 Email: Contractor.coordination@pgn.com CONTRACTOR INFORMATION ❑ Same as applicant Name: Potelco (Mark Persche) CCB Number: 76668 Mailing address: 14103 Steward Rd City/State: Sumner, WA Zip: 98390 Phone: 503-307-2960 Email: MRPersche@potelco.net ENGINEER INFORMATION Name: PGE - Rick Eisenblatter Mailing address: City/State: Zip: Phone: 971-272-6110 Email: rick.eisenblatter@pgn.com ADDITIONAL INFORMATION Estimated value of work is required(if over$5,000):$ (within the public right-of-way) Is work related to a LAND USE DECISION? ❑Yes ❑No Case number: City of 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. 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. Nance Stone oe' '202205.0tyy4 Nance: 5-0roo' Nance Stone 05/04/22 Applicant's or authorized agent's signature Print name Date Property owner's signature (if required) Print name Date STAFF USE ONLY Case No: PF12022-00187 Permit fee: Received by: SPV Date: 5/4/2022 Approved by: T tGf<7f /6- Date: Sl S ,1 2122 Notified by: ��_Date: S'S 2L City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • 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 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 • 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 ❑ 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 Propertti• ❑ 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.figard-or.gov • 503-718-2421 • Page 3 of 4 Edge of Pavement IFAL6 DitchStreetlight I —1 1 N; Existing House 1 ar I Existing 1 Driveway IL r of , II I CF,o; 1E� I 1 of , Existing Shop Powerpole I 1 .� o 1 1� 95 — — — I , 7roperty Line 1 Fire Hydrant(FH) I i I � I scale: t"=30' � I I I I I I I I TYPE 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 of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.figard-or.gov • 503-718-2421 • Page 4 of 4 75 Q. INSTALL ADDIT 11550 $ .a n m + POLES POLE C c HT-CL —' POLE H 30 A —6 ZAL 7980 a FRAMING TRANSMISSION& DI TIGARD ST 4-AL 3- B4/o D11 237' ALCTX 3. a AB6CU 197' pen +265T C11-34D M'- ° : 5872 5872 4690 1954 45-3 45'-4 11600 1973 11200 PL-5872 wl , INSTALL: m o PL45'-3 c 2' EAST m ; D11 ZIPLY OWNED POLE ZIPLY TO PULL \W-Urtn�— D ---� TEMP TRANSFER COMM(S), PGE PULLED rTOPPED TO COMM(S) RIGHT-OF-WAY PERMIT NOTICE: A PERMIT FROM THE LOCAL JURISDICTION IS REQUIRED BEFORE ANY WORK IN THE RIGHT-OF-WAY MAYBE PERFORMED. ONLY PGE APPROVED CONTRACTORS AND CONTRACTORS WHO HAVE MADE OTHER SPECIAL AGREEMENTS WITH PGE WILL BE ALLOWED TO WORK UNDER PGE'S PERMIT. THE CONTRACTOR MUST NOTIFY THE LOCAL JURISDICTION 48 HOURS PGE CONSTRUC BEFORE WORK IS TO BEGIN. A COPY OF THE PERMIT MUST BE ON SITE. DATE: 10/26/2021 SCALENTS ACCOUNT: TE TITLE 0 ANY DEVIATION FROM THIS DESIGN MUST ` OVERHEAD CAPITAL FITS BE APPROVED BY PGE PROJECT MANAGER \\ CIRCUIT TIGARD - 13361 —� ATTENTION: CALL 811 BEFORE YOU DIG �GE LOCATION ....��.... .,....�,. .,,.,.--�,,, 1 ,,,.,...., -- ---- � / 11200 SW TIGARD ST. T 2011 Edition Page 85 Stationary Lane Closure with Flagging Diagram 320 0 Y W \\ • C oo� w O 0 0¢� m m � Wo / � •� o m N • m c •• m am I • >o c u C L co B R 1 t I oar 11 I • 3 I r � • ,� I o �� I • m • I t 07 � �l� �� I • aD CLE I Q E o^ �� ' • (D;v j•. • caoa ® I • I �Jp p: • � I a / o Wa �� 1 0/ 4 t m W Y� �' a ———————————————— I m Sian Siacing and Buffer Lengths feet Postetl 5 acin Between Signs "eWfer" Z o❑ ca Speed A 8 c Space \ W<S p 20 50 Z W Q O 25 100 100 100 75 I O 30 100 125 40 350 350 350 150 <@>ccAS 80 50 500 500 500 210 55 250 60 285 65 700 700 700 325 70 365 September 2016 Chapter 5