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PFI2014-00034 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12014-00034 * 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 07/24/2014 Parcel: SEG294 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: NW Natural Project Description: Adjacent to 11575 SW Hazelwood Loop. Install shirt side service. Main on the Z in ROW. Possible street cut. SEG 294 Owner: FEES Description Date Amount PHONE: PFI Permit Fee 07/24/2014 $300.00 Contractor: PHONE: FAX: Applicant: JUDY DOBLIE 220 NW 2ND AVE PORTLAND, OR 97209 PHONE: 503-226-4211 Total $300.00 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: no+ Issued By: A& Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12014-00034 Type: Condition Name: Status: Severity: ROW 10-TRAF CTRL-MIN LANE WIDTH Continuing Notice Minimum travel lane width shall be eleven(11)feet; pedestrian travel shall also be provided for. ROW 26-MONUMENT PROTECTION REQ Continuing Notice Existing monuments, property corners, and survey markers shall be protected. Replacement shall be at the permit holders expense. ROW 13-HAZARDS-CERT OF INS Continuing Notice Maintenance of the work area and approach roads is the responsibility of the permit holder.The work area and approach roads shall be maintained in a clean condition,free from obstructions and hazards.A copy of the permit holders Certificate of Insurance shall be available at the work area. ROW 19-UTILITY LOCATIONAL CONFLICT Continuing Notice Contractor 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 permit holders expense. Changes must be approved by the City in advance of work performance. Contractor shall coordinate the work with affected utility agencies. ROW 27-PROB SOLVING-RESPON PARTY Continuing Notice The permit holder shall 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 an emergency. The permit holder shall notify the City Inspector, in writing, of any/all assignment changes. ROW 20-TRENCH-PATCH/SAFETY/LBILITY Continuing Notice A temporary hard-surface patch (Cold mix A.C. or Hot mix A.C. base paving) shall be placed on trenches within roadways at the end of each day's work. No trench, on site or off site, shall be left at any time in an unsafe condition.The permit holder is responsible for and is liable for hazards or damage resulting from the work. ROW 21-REPAIRS REQ-INSPTR OPINION Continuing Notice Work provided for under the permit shall include repair of existing facilities(roads,ditches, etc.)as may be necessary, in the City Inspectors opinion, to overcome deterioration or damage which occurred in conjunction with the work authorized by the permit. Corrective work shall be done at the permit holders expense. ROW 23-DAILY INSP REPORTS REQ Continuing Notice The permit holders Engineer/Inspector shall submit daily inspection reports, on a weekly basis,to the City's Inspector. (see Developer-Engineer Agreement note#5). ROW 29-ESMT/RT OF ENTRY-RESPON Continuing Notice It is the sole responsibility of the permit holder to provide for 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 permit holder's failure to obtain or provide for proof of right-of-entry or easements. ROW 06-TRAF CTRL-ADVANCE WARNING Continuing Notice Advance warning of imminent traffic disruption shall be provided to the general motoring public by placement of an advance notification sign at each end of the construction area 72 hours(min.)before initiation of construction work. ROW 04-TRAF CTRL-CONTR RESPON FOR Continuing Notice Traffic control shall be provided for by the contractor in accordance with the City's standard specification and, also, in accordance with a City(job specific)approved traffic control plan.A copy of the approved traffic control plan shall be available at the work area. ROW 05-TRAF CTRL-ROAD CLOSURE Continuing Notice Public roadway shall not be closed to traffic, at any time,without having first obtained written approval from the City Engineer.The permit holder is responsible for provision of timely notification of traffic flow disruptions to area wide Emergency Services(Tigard Police Dept.,Tualatin Fire& Rescue)and to Tri-Met and Tigard School District. ROW O8-TRAF CTRL-DEVICES IN PLACE Continuing Notice Traffic control devices,flagpersons, etc., shall be in place prior to initiation of construction work and shall be effectively maintained. ROW 16-REPAIRS-LIKE MATERIALS REQ Continuing Notice Property disturbed by construction activity shall be seeded with a standard grass mix; shrubs,flowers, barkdust, existing signs, pavement markings, mailboxes, etc., shall be reestablished, reinstalled or replaced,with like kind and material. ROW 18-UTILITIES PRELOCATION REQ Continuing Notice Oregon law requires following the rules adopted by the Oregon Utility Notification Center. Said rules are set forth in OAR 952-001-0010 through OAR 952-001-0080. Copies of the rules may be obtained from the Center by calling(503)232-1987. If you have questions about the rules, contact the Center. NOTE: Damage to utilities shall be corrected at the permit holders expense. ROW 17-DRAINAGE CONTROL REQ Continuing Notice Effective drainage control is required. Drainage shall be controlled within the work site and shall be so routed that adjacent private property, public property and the receiving system is not adversely impacted. The City may, at any time, order corrective action and stoppage of work to accomplish effective drainage control. ROW 24-TESTS/REPTS TO VALIDT CLMS Continuing Notice The City's Inspector may, at their discretion, require provision of tests and or reports from the permit holder, permit holder's engineer or contractor to validate claims of material or construction adequacy/compliance. Such tests/reports shall be provided at the permit holder's expense. ROW 25-RELEASE-WAIVER REQ Continuing Notice The permit holder shall provide a copy of a properly executed Release&Waiver document to the City for each ownership disturbed by construction activity, as evidence of disturbance resolution and owner satisfaction. ROW 01-CUSTOM CONDITION Continuing Notice <Custom Condition goes here> ROW 02-PERMIT& PLAN REQ ON SITE Continuing Notice A copy of the permit and all attachments, and a copy of the approved construction plan and all amendments shall be 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 the aforesaid must be approved by the City, in advance of work performance. ROW 03-TRAF CTRL-SPECIF(CITY) Continuing Notice The City's standard specification for traffic control is"Manual on Uniform Traffic Control Devices for Streets and Highways", U.S. Dept. of Transportation, F.H.A., 1988 Ed. ROW 09-TRAF/NOISE CTRL-WORK HRS Continuing Notice No work will be permitted during the hours of darkness, nor between 9:00 p.m.to 7:00 a.m. Monday through Friday, nor between 9:00 p.m.to 8:00 a.m. Saturday, nor between 9:00 p.m.to 9:00 a.m. Sunday. ROW 11-TRAF CTRL-CITY CAN MODIFY Continuing Notice The City reserves the right to add to or modify traffic control requirements as may be necessary to effectively control traffic and to assure public safety. ROW 14-DEBRIS-MATERIALS Continuing Notice 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 cleanup and stoppage of work to accomplish cleanup. ROW 12-INSP 24 HR NOTICE REQUIRED Continuing Notice The permit holder or his contractor shall notify the City's inspector Kenny Fisher at 503-816-6146 or email at kenny@tigard-or.gov, twenty-four(24) hours prior to commencing work, twenty-four(24)hours prior to any staged inspection, and after completing work covered by the permit. ROW 15-EROSION CTRL REQ Continuing Notice Effective erosion control is required. Erosion control devices must be installed and maintained meeting D.E.Q. requirements.The City may at any time order corrective action and stoppage of work to accomplish effective erosion control. ROW 22-AS-BUILT/ENGR CERTIF REQ Continuing Notice At the end of each year, or an a mutually agreeable yearly date, any entity making changes to its facilities in the public right-of-way shall submit complete"as-built"drawings 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(form attached). ROW 28-CONSTR SAFETY-RESPON PARTY Continuing Notice The permit holder shall cause his contractor to provide to the City Inspector, in writing,the name and 24 hr emergency telephone number of a designated"Competent Person"responsible for construction safety as per OR-OSHA, Chap. 437, Div. 3 Construction, Subdivision P-Excavations.The contractor shall notify the City Inspector of any/all assignment changes. ROW 07-TRAF CTRL-PRIV PROP ACCESS Continuing Notice Access to existing properties shall be maintained at all times, including normal delivery service and mail service and if not, shall be cause for work stoppage until effective access is established VjEcE.NED City of Tigard JUL 21 M4 _ Public Facility Improvement CITY OF T►GARD PLpNNINGIENGINEtRtNI 31 Permit (PFI) Pit General Information: FOR STAFF USE ONLY Property Address/Location(s): 11575 SW Hazelwood Loop Engineering F(l2 T1 T' I—CCo3T l I WR# 3416365 Case No.: TT � �� Fee: T JO O�2 Receipt No.: *Applicant's Name: NW Natural Date: Address:220 NW 2nd Av Application Accepted.-712.1114 By:-M4- City/State: y:-MLCity/State:Portland OR Zip:97209 , Primary Contact:Judy Doblie REQUIRED SUB ITTAL Phone: 503-226-4211 X 4428 Fax:503-273-4822 INFORMATION n6-�cl-"1�2 �l � 4(I - F�.-Mail: nwnpermits@nwnatural.com Professional ngineered Plans are req.uired for: Contractor's Name:Loy Clark/Wanda Taylor • Street Widening • Subdivision Infrastructure CCB#52281 Expiration: • Main utility line extension: Address: PO BOX 1369 0 Storm Drain,Sanitary-Tigard City/State:Tualatin OR Z 0 Water—Tigard Water Service Area Zi97062 p: (includes Durham,King City and a 503-783-1171 503-520-8763 portion of unincorporated Washington Phone: Fax: County) "Note:See Engineered Plan Plans By: Submittal Checklist attached. Address: For all other work: Submit scaled sketch of the City/State: Zip: work to be done. (see attached minimum sketch Phone: Fax: requirements and provided sketch area). Updated:6/24/2013 I:\CURPIN\Masters\land Use Applications\Public I-acdity Description of work: Install short side service. Main on the 2' in Impruvementdocx ROW. Possible street cut. Estimated value of work(within the public right-of-way): $ Is work related to a LAND-USE DECISION? YES F-1 NO If so,please specify (MLP,SDR,SUB,etc.) case#: Is the work related to a BUILDING PERMIT? YES❑ NO If so,please specify (BUILDING PERMIT)case#: City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 1 of S APPLICANTS: To consider an application complete,you will need to submit ALL of the REQUIRED SUBMITTAL ELEMENTS as described on the front of this application in the"Required Submittal Elements"box. NOTE: Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for work. *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(s)must sign this application in the space provided on the back of this form or submit a written authorization with this application (Detailed Submittal Requirement Information sheets can be obtained,upon request,for all types of Land Use Applications.) BY SIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT: ♦ The above request does not violate any deed restrictions that may be attached to or imposed upon the subject propea, ♦ If the application is granted,the applicant will exercise the rights granted in accordance with the terms and subject to all the conditions and limitations of the approval. • All of the above statements and the statements in the plot plan, attachments, and exhibits transmitted herewith, are true; and the applicants so acknowledge that any permit issued,based on this application,may be revoked if it is found that any such statements are false. ♦ The applicant has read the entire contents of the application,including the policies and criteria,and understands the requirements for approving or denying the application. SIGNATURES of each owner of the subject property. DATED this 14th day of July 2014 Digitally signed byJudy Doblia DN:cn=Judy DobGe,o=NW Natural, ou,email=jkd@nwnatural.=n,FUS Date:2014.07.14 10:55:44-07100' Applicant/Authorized Agent's Signature Owner's Signature Owner's Signature Owner's Signature City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 2 of 5 t2•�41� � J BERRY R0P� SGHD��S SW' N 5]! 7 r Os�Y�o v0 14 `o �y 237 (7s) 69 #11735140- 9 fi .,,Seo �1e1 +70 ♦ a I-(M75 I 2 (VY) rKi k#ntaw 1Gvp Ipl "b, }'i>y ass. asi �i NW Natural PLAT: 1-041-017 COUNTY: WASHINGTON 07/14/14 10:5 (503)2264211 TOWNSHIP: T01S RANGE: R01W SECTION: 34NW SCALE: 1 IN = 100 FT LTJ USER ID:jkd y 134B 0 34BO58C 340059 C2! a Bo�J,, , 346060F 10 650 5534 B048 10650 10650 10650 10650 10650 10650 10650 1.0650 1 10650 10650 1065010650 j 3480�F 10650 S340001 10650 S S34 6042 ��A g•, 113 . 11375 11595 11575 S 4B002 as 11605 11555 15„ 3460JAC SS B01Y�ya 6" pIP �34BL B0133 `-.� 34601 SS34A082 ® S348012 SS3 6004 IN B014 C' 3460132346 13 �4B0134 � 1 11 8 Ci S' 11600 Op C/A O �' �SS340014 3" 14/ 1 2 ' 115 ►+ Q�00 O� a VL lab IA An 348D135SS 346013 Feet 3480138 0 125 � i � 346025C /�