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PFI2015-00185 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12015-00185 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 12/16/2015 Parcel: SEG1049 Jurisdiction: Tigard Site address: 12517 SW-1-23RD-AVE -- — Subdivision: Lot: Project: Utilities NW Natural PFI @ 12517 SW 123rd Ave Project Description: Install long side SVC; main is 2'inside PUE. Possible cut for Pot hole over other utilities Owner: FEES Description Date Amount PFI Permit Fee 12/16/2015 $300.00 PHONE: Contractor: PHONE.- FAX: HONE:FAX: Applicant: AISHA PETERSON 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 p Signature: (j _ VI Issued By: (n�^� U C_Gw+.L✓ Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12015-00185 Type: Condition Name: Status: Severity: 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 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 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. FA—HaES �rweoLe j i W i ��S-t¢ -�ITM Q f•RA RTN O 6 ; p�• O C q _ a•a RAYRL 7 > p p C ISM) � n CCC ' � oc t¢ R6 W � I �-3 3 x W = o (78) 276 �1 1112512 cd 43' a i P �r 211' (Wj30' 635' `s g *12522 .2 (7a) 367 Maw 12517 SW 123rd Ave, #3456861 —/ o or •12800 ,� � Iwo �� � 3 gar �• � 304' 6 2 imam c ,g ~b ui m P) N12800 �'� ,36 S� �P s aa S4B' -T— NW Natural PLAT: 1-043-017 COUNTY: WASHINGTON 12/09/15 08:30 (503)226-4211 TOWNSHIP: T02S RANGE: R01W SECTION: 3NW SCALE: 1 IN = 100 FT USER ID:aap REGEp`,ED City of Tigard DEC 10 2015 PUBLIC WORKS — ENGINEERING C Public Facility Improvement (PFI) Permit - DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL Check one: 8 Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS Detailed description: Install long side Svc; main is Z inside PUE. ❑ Minor work in right-of-way (sidewalk repair,curb cut,street Possible cut for pot hole over other utilities/MIR#3456861 opening,etc.)requires: •Application form,completed and signed •Submit one(1)copy of scaled sketch Proper , address/location(~ 12517 SW 123rd Ave of the proposed work to be done C_C-1 k 04 CI •Submit one(1)copy of traffic control plan –OR– A OR– Applicant's name: NW Natural/Aisha Preston E] Substantial project work requires pP above items and professional Address: 220 NW 2nd Ave engineered plans for: Portland, OR 97209 •Street widening City/state: Lip: •Subdivision infrastructure Phone: 503-226-4211 x4428 Email: nwnpermits@nwnatural.eom •:Main utility line extension: Storm Drain,Sanitary-Tigard Mater-Tigard Water Service Contractor's name: Loy Clark area(includes Durham,King City CCB#: 52281 Expiration: and a portion of unincorporated Address: PO Box 1369 Washington County) City/state: Tualatin, OR Zip: 97062 DELIVER APPLICATION TO: 503-783-1177bin. unor to clark.com City of Tigard Phone: E-mail:Iil1 @ Y Planning/Engineering 13125 SW Hall Blvd. Engineers name: NW Natural/Andrea Kuehnel Tigard,OR 97223 220 NW 2nd Ave Applications for"minor work in right-of-way" Address: only may be emailed to: City/state: Portland, OR Zip: 97209 rownermits&tigarrd-or�gov Phone: 971-409-7594 Email: afk@nwnatural.com FOR ONLY Case No.: r FL Z U 15 - 00 1 415 Estimated value of work (within the public right-of--way): $ Application submittal fee: —?N 6` Is work related to a LAND-USE DECISION? ❑ Yes ❑ No Application accepted: If so,please speci6} (MIT, SDR, SUB, etc.) case #: By: M (5 Date: 12/10/is Is work related to a BUILDING PERMIT? [JYes ElNo Applicatin reewed: If so,please specify(BUILDING PERMIT)case#: By: Date: 4/Z- q � Applicant notified: tofvV4 � ;-,-w - /OC4.� /4 K�L By: Date: f y 777 I:\CURVLN\Masters\land Use Applications Rev.07/16/2014 City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page I of 4 APPLICANTS 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 sibm this applieafion in the space provided or submit a written authorization with this application. BY SIGNING BELOW, THE APPLICANTS) SHALL CERTIFY THAT: • The above request does not violate any deed restrictions that may be attached to or unposed upon the subject 12roperty • 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 required. Digitally signed by Aisha Preston DN—AisuhanwPreston,.cum, Aisha Preston 12/10/15Aisha Preston ma -US Dale.2015.12.10 13.17:05-08'00' Applicant/Authorized Agent's signature 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.gm, 503-718-2421 • Page 2 of 4