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PFI2015-00073 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12015-00073 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 06/10/2015 Parcel: SEG2265 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: Comcast Cable Project Description: Adjacent to 10940 SW Highland Drive. Directional drill from the ped, on the east side of SW Highland Drive going west 33'across road, placing 3/4"pipe with CATV to service 10940 SW Highland Drive. Owner: FEES Description Date Amount PFI Permit Fee 06/10/2015 $300.00 PHONE. Contractor: PHONE: FAX Applicant: RANDY SHIELDS 11308 SW 68TH PKWY TIGARD, OR 97223 PHONE: 360-301-1962 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 Not Present Signature: Issued By: ---�_ I Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12015-00073 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 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 09-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 10-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 11 -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 12-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 13- 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 14-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 15-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 16-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 17-NOTICE TO COMMENCE WORK Applied Notice The applicant 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, prior to any staged inspection,and after completing work covered by the permit. PFI_Utilities 18-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 19-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 20-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 21 -OTHER Applied Notice RECEIVED JUN 0 4 2015 City of Tigard CITY OF TIGARD PUBLIC WORKS—ENGINEERING PLANNING/ENGINEERING Public Facility Improvement (PFI) Permit DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL Check one:El Utilities ❑ Sidewalk/driveway approach ❑ Street improvements EIXIAENTS Detailed description: Directional drill from the ped, on the EAST El Minot work in right-of-way side of SW HIGHLAND DR going WEST 33 across road placing 3/4" (sidewalk repair,curb cut,streetopening,etc)requires: pipe with CATV to service 10940 SW HIGHLAND DR, 97224. •Application form,completed and signed •Submit one(l)copy of scaled sketch Properly address/location(s): 10940 SW HIGHLAND DR, 97224 of the proposed work to be done na/„ •Submit one(1)copy of traffic OC �L control plan -OR- Substantial CABLE ❑ Substantial project work requires Applicant s name above items and professional Address: 11308 SW 68TH PKWY engineered plass for: City/state: TIGARD, OR zip: 97223 •Subdivision infrastructure Phone:360.301.1962 Email: Randy_Shieldsecable.Comcast.com •Afain utility line extension: - Storm Drain,Sanitary-Tigard Fisk Communications Contracting, INC. - Water—Tigard Water Service Contractors name Area(includes D ri m,fCwg City CCB#: ORCCB# 185632 Expiration: and a portion of unincorporated Address: 2705 NE 65th AVE Washington County) City/sate Vancouver, wA Zip: 98661 DELIVER APPLICATION TO: City of Tigard Phone:360.314.4454 Zip: City Planning/EngMeering 13M SW HaH Blvd. Tigard,OR 97123 EngiIIeei s mule: Address: Applications for"minor work is right-of--wry' only may be emailed to: City/state: Zip: Phone: Email ME Estimated value of work(within the public right-of-wmy): $±0_0-_00 CawNo Application submittal feel 3.00 Is work related to a LAND-USE DECISION? ❑ Yes ® No Application�accepted: If so,please specify PAU,SDR,SUB,etc.)case#: By: Date 1� Is work related to a BUILDING PERMIT? ❑ Yes ® No Applicationrevlewed: If sp,please specify(BUILDING PERMM case#: Br6•4 •/sem Applian nn Bp: Dace: �l 15 1�cuMUWrlua10µrwlb-, Yotlais AMA 9YA MA City of Tigard • 13125 SW Hal Blvd. • Tigard,Orrgon 97223 www.figard-or.gov 503-718-2421 • Page 1 of 4 APPLICANTS NOTE: Person specified as"Applicant"shall he designated"Permittee"and shall provide financial assurance for work. xMien the owns and die applicsutt nue different people,die applicaru must be the pufclaser of record or a lessee SII possession with wutten andloriution from the owner or a»agent of the oumer. 'Illc owner($)must sign this application ni the space prcmided or submit a written authorization wide dun application. BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT: • 'I7te above r west does not violate ani deed restriefions that may he attached to or imposed upon the suboect rrooper4. • 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=ht $oZ the subject property required. —:7 U C:4 Athena Logan 6/3/15 ppcant/Author t' si tore Print name Date Owner's signature Print name Date Owner's signature Print name Date Owner's signature Print name Date PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov 503-718-2421 • Page 2 of 4 DEVELOPMENT ENGINEERING FEES I. Public Facility Improvement(PFI)Permit: Part 1: Required submittal fee$300.00 Part 2. All non-water system improvements Engineer's estimate X 59/b(less$300.00 submittal fee) Engineer's estimate X 20/6 Plan Review Pert 3: All public water system improvements En&eeA estimate X 120A Total Permit Fee=Part 2+Part 3 PFI Permit Fee Exemptions: There will be no permit fee charged,or assurance required for the following types of work: • Sidewalk or driveway repair(less than 20 lineal feet) • Relocate or replace mailbox • Ditch cleaning that does not involve regrading, • Weephole repair • Curb repair or replacement(less than 20 lineal feet) • Lawn sprinkler system installation or repair • Street tree pruning or planting • Planter strip landscape maintenance • Test wells PUBLIC FACILITY D"ROVEMEN T PERMIT City of Tigard • 13125 SW HallBlvd. • Tigard,Oregon 97223 0 www.dgW-orgov 503-718-2421 Page 3 of 4 Edige of Pavement Ditch Streetlight I — —•—•— —•— —C—.� ° � /• FW Ttm Rain n I 1 1 II N Existing House m� I Existing 1 21 Driveway . a I1 d w I o, o' •� I al 4� I j 6u"ing Shop Powe` I o l o 1 I a 95' 1 0-------F-ropertyUne-------s---- � I iFire Hydrant(FH) � I I Scale: 1'=30' � 1 I � I I j I I j � I MINIMUM SKETCH REQUIREMENTS(Put"N/A"if Not Applicable): North arrow Property lines&dimension Slope of property Street&street name(s) Existing budding,structures Utility&street light poles Proposed work Existing curb or edge Trees Existing S/W or of pavement Existing utility locations D/W apron (sewer,water,storm) PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard - 13t25 SW Hall Blvd. - Tigard,Oregon 97223 - wwautigard-or.gov 0 503-718-2421 , Page 4 of 4 �'oYl01'�.,,�QY.�• ��� P.Pp Rom ".Stoll PA&7)kOD Qikt�N� 1041 t 019c) ?,1 141 6f 6W- 3 �o— ,-0 lw° 33 ,� {�E al- H /to'r } AVE , i 10c�2-5 101935' AVE zo m , G) MEN Fisk Communications Z> o m `� Contracting Inca Z �' (3 60) 314-4454