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PFI2016-00067 4 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12016-00067 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 03/30/2016 Parcel: SEG319 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: PGE Project Description: Adjacent to 11480 SW Hazelwood Loop. Replace 175'b/o secondary UG service. Conduit to be installed by PGE approved contractor. Owner: FEES Description Date Amount PFI Permit Fee 03/30/2016 $300.00 PHONE: Contractor: PHONE: FAX: Applicant: LINDA SADDLER 10800 SW AVERY ST TUALATIN, OR 97062 PHONE: 503-612-6103 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: Not Present Issued By: _-C_�/hi� Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12016-00067 Ty pe: 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 riot 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 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. Kenny Fisher @ 503.816.6146 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 MAR 2 8 2016 City of Tigard CITY O ! PUBLIC WORKS —ENGINEERING PGE WORK 08 G Public Facility Improvement (PFI) Permit DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL Check one: N Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS Detailed description: Replace 175' b/o secondary UG service. ❑ Minor work in right-of-way (sidewalk repair,curb cut,street Conduit to be installed by PGE approved contractor. opening,etc.)requires: •Application form,completed and signed •Submit one(1)copy of scaled sketch Property address/location(s): 11480 SW Hazelwood Lp of the proposed work to be done •Submit one(1)copy of traffic ZI control plan -OR- Applicant's name: Linda Saddler El Substantial project work requires PP above items and professional Address: 10800 SW Avery St engineered plans for: Tualatin OR 97062 •Street widening Ci /state: Zip: •Subdivision infrastructure Phone: (503) 612-6103 Email: T&DSupportAvery@pgn.com •Main utility line extension: - Storm Drain,Sanitary—Tigard - Water—Tigard Water Service Contractors name: TO be determined. Area(includes Durham,King City CCB#: Expiration: and a portion of unincorporated Washington County) Address: City/state: Zip: DELIVER APPLICATION TO: City of Tigard Phone: Email: Planning/Engineering 13125 SW Hall Blvd. Engineer's name: Tom Cox, Portland General Electric Tigard,OR 97223 2213 SW 153rd Dr .`Applications for"minor work in right-of-way" Address: only may be emailed to: City/state: Beaverton OR Zip: 97006 rowpermits .tiga� or.w Phone: (503) 867-0414 Email: tom.cox@pgn.com ➢`-��J� QW�� Estimated value of work (within the public riCase No.: ght-of-way): $ 22 Application submittal fee: d� Is work related to a LAND-USE DECISION? ❑ Yes R No Application accepted: If so,please specify (MLP, SDR, SUB, etc.) case #: By: Ls Date: Jp a Is work related to a BUILDING PERMIT? ❑ Yes 8 No APP cation r 'ewed: By: Date: 3 LL If so,please specify(BUILDING PERMIT)case#: Applic n tified: By: Date: 3 l:\CURPLN\Masters\LandUw Applications Rev 07/16MU City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 www.tigard-or.gov 0 503-718-2421 • Page 1 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 sign this application 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 imposed upon the subject<propery. • 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 Linda Miller(Saddler) Linda Miller(Saddler) ON;—Un nda ,=,,rSaddddler=PgrtlarMGeUS Linda Saddler for Tom Cox 3/25/16 Electric w.email=lmda.26-OTr�Pgn.mm.SUS Data:2016.0326 06.03.26-0T00' 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 • www.tigard-or.gov 503-718-2421 Page 2 of 4 DEVELOPMENT ENGINEERING FEES 1. Public Facility Improvement(PFI) Permit: Part 1: Required submittal fee$300.00 Part 2: All non-water system improvements Engineer's estimate X 5% (less$300.00 submittal fee) Engineer's estimate X 2%Plan Review Part 3: All public water system improvements Engineer's estimate X 12% 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 IMPROVEMENT PERMIT City of Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2421 Page 3 of 4 SAMPLE SKETCH: 'st. Edge of Pavement I f— Ditch Streetlight I — —•—•—•—•—•—•—C—•— a Raab Dram f t Tr 1 0 1 � I • ' T 'p'os d"Se1werTine'— Existing House 1 I I Existing j ,. �i Driveway IL a I I cr,e �� 1 "I ii I 1 O � I Existing Shop � J Powerpole Q o 5 I--------7'p FI 7n e'-----...--- II Fire Hydrant(FH) � I I Scale: � I I � I � � I I � � I MINIMUM SKETCH REQUIREMENTS (Put'IN/A"if Not Applicable): North arrow Property lines &dimension Slope of property Street& street name(s) Existing building, 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 • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 4 of 4 WR CHECKLIST LEGEND I L� ITEM YES COMMENT 11575 11555 / REMOVE FACN/TIES _INSTALL FACILITIES 0 25 50 100 Feet HOLEDIGGER 11535 P 1 I I I I I I BOOM BACKHOE INSTALL ADDITIONAL FACILITIESMODWY FACILITIES 650 / PGETRENCH 30'-4 ` BORE X 175 FT CONDUCTORS 1976 11515 LOCATES X ------• INSTALL 1J,tl AL-TX SECONMRYIN 1-3'PVC CONDUIT ew NAS, C 5O 17273, STAKING PROVIDED A INSTALLED BY POE APPROVED CONTRACTOR L�VD�y, VT-147 "Lp0 FLAGGING X I OW ARANDON R SU, TREETRIM WL2. LANDSCAPE "'tailEASEMENT (175)CONTRACT BORING 11495X TIGARD 07511-RUN OF 4/0 AL URD TX �Y PERMITS 11580 1-3"PVC 2 yq� TRAFFIC PLA p1N- x(11751-RUN OF 4/0 AL URD TX R C4j Ib9 Y�O CUTSHEET 1-LINE DIAGRAM O UG CIR.VER. _ >.TfSyT0.GrA <0 Citi SHUTDOWNION so r.4 - 11520 �'ri y. Q "7j 64 a 1147' SHUTDOOWN X 1 CUSTOMER �. h 9 3 DOOR HANGAR V. 11570 C9 CONTACT y� 655 COMPANY 30'4 PH7t C# 6 TE TIME // 11480 11530� � V.D=0.32% 11456 � THINK 11560 SAFETY ILC. �� 11460 `� FIRST ,� r a vT-147 C 50 17251 11550 11540 11475 1'4- PGE Vicinity Map t NYDEIIII17ONFROM ThUMIGNM BEAPPROVED BY THE PGE PROJECT MANAGER PGE CONSTRUCTION DRAWING 1� RIGHT-OF-WAY PERMIT NOTICE: AS-BUILT VERIFICATION&NESC VIOLATIONS CORRECTED �Sexv� sB 210 A PERMIT FROM THE LOCAL JURISDICTION IS REQUIRED BEFORE ANY Foreman: Date: p{LY Fv WORK IN THE RIGHT-OF-WAY MAYBE PERFORMED. ONLY PGE APPROVED General Foreman: Dale: S11 MINEER IN SG1{OUL`' - CONTRACTORS AND CONTRACTORS WHO HAVE MADE OTHER SPECIAL L AGREEMENTS WITH PGE WILL BE ALLOWED TO WORK UNDER PGE'S PERMIT. SpPA1�E7yG REVIEW ASBUILT BYDESIGNER Sw S""$11.K THE CONTRACTOR MUST NOTIFY THE LOCAL JURISDICTION 48 HOURS DATE. SCALE. accouNT awo: r 1Sp¢ tw woNwooD Lour•op BEFORE WORK IS TO BEGIN.A COPY OF THE PERMIT MUST BE ON SITE. 01/26/2016 1"=50' 5940001 0000014628 1 M1990580 v OF nrLE REPLACE 175'B/O SEC UG SVC AT 11480 SW HAZELWOOD LOOP CALL 811 BEFORE YOU DIG CIRCUIT g, a ATTENTION: ` PROGRESS-ROBINSON SIZE11x17 u~ia' SN OREGON LAWREQUIRES YOU TO FOLLOW RULESAOOPTED ��//��C LOCATION n Cr, BY THE OREGON UTILITY NOTIFICATION CENTER. , AVE/ 11480 SW HAZELWOOD LOOP.,TIGARD,OR 3� 2 CO I Io,O SYy j THOSE RULES ARE SET FORTH IN OAR 95 2 001-0010 DE RIP7 N T THROUGH 951-001-0090 YOU MAY OBTAIN COPIES OF aq x LN REPLACE 175'B/O SEC UG SVC AT 11480 SW HAZELWOOD LOOP "Ell SW < THE RULES BY CALLING THE OREGON UTILITY gEAVERTON '0,u, OU SECTIONS IGpgN It Cpea i NOTIFICATION CENTER ADMINISTRATION IN(502-232-1987) LINE CENTER WASHINGTON C1134B SW 7O REQUEST UTILITY LOCATES CALL THE OREGON a�IBYBISb�IK DESIGN BY oN /wJ DRAWN BY 1 of t � � s sw MAN7AM7 s 1 Y eLLSON PGE UTILITY NOTIFICATION CENTER,811 AT LEAST Qd bM018 J111111� Wil RlON q)-(106 TOM COX 867-0414 HUGO MEJIA 2 BUSINESS DAYS PRIOR TO EXCAVATION 0 PORTLAND GFNFRAi FI