PFI2016-00087 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
G COMMUNITY DEVELOPMENT Permit#: PF12016-00087
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 05/04/2016
Parcel: SEG1049
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Frontier Communications
Project Description: Adjacent to 12517 SW 123rd Ave. Directional bore under 123rd Ave.to place new fiber drop.
Owner: FEES
Description Date Amount
PFI Permit Fee 05/04/2016 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
SCOTT ALBERT
4155 SW CEDAR HILLS BLVD
BEAVERTON, OR 97005
PHONE: 503-526-3544
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:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12016-00087
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 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
APPLICATION FOR APR 2 8 2016
PUBLIC FACILITY IMPROVEMENT (PFjl� * -RING
Engineering Department CITY OF TIGARD
13125 SW Hall Blvd., Tigard, OR 97223(503)639-4171 FAX.- (503)624-0752
FOR STAFF USE ONLY
General Information:
Engineering 7�,_/0D/�^ )
Property Address/Location(s): 12517 SW 123RD AVE . Case No.: r-'` >
N/0 SW WALNUT ST. Receipt No.:
Date:
*Applicant's Name: Frontier Communications Application Accepted By: it L
Address: 4155 SW CEDAR HILLS BLVD. ea4/1si 3 2D/C,
City/State: BEAVERTON, OR. Zip: 9 7 0 0 5 — c�
PrimaryContact: SCOTT ALBERT REQUIRED SUBMITTAL INFORMATION
Phone: 503-526-3544 Fax: 503-641-0977
Professional Engineered Plans are
required for:
Contractor's Name: SONICOM CONSTRUCTION
CCB# OR#18 8116 METRO#10 15 7 Expiration: • Street Widening
• Subdivision Infrastructure
Address: 1275 S KODIAK CIRCLE . Main utility line extension (Storm
City/State: CORNELIUS OREGON Zip: 97113 Drain, Sanitary and Water)
Phone: 503-519-3445 Fax:
'*Note: See Engineered Plan
Submittal Checklist attached.
Plans By: FRONTIER (SCOTT ALBERT)ATTACHED.
Address: For all other work: Submit scaled sketch
of the work to be done. (see attached
City/State: Zip: minimum sketch requirements and
Phone: Fax: provided sketch area).
Description of work: DIRECTIONAL BORE UNDER 123RD AVE . TO PLACE NEW FIBER DROP .
Estimated value of work (within the public right-of-way): $
Is work related to a LAND-USE DECISION? YES ❑ NO ❑
If so, please specify(MLP, SDR, SUB, ect.) case#:
Is the work related to a BUILDING PERMIT? YES ❑ NO ❑
If so, please specify (BUILDING PERMIT) case#:
*NOTE: Person specified as "Applicant" shall be designated "Permitee" and shall provide
financial assurance for the work.
ENGINEERING DEPARTMENT FEES
1. Public Facility Improvement(PFI) Permit:
Applicant must pay a fee equal to 5%of Estimated Cost of Public Improvement,with a minimum fee of$300.00.
Fee to be paid as follows:
1. Upon submittal of plans $300.00 non-refundable intake fee.
2. Prior to release of first red line set Balance of fee is due.
NOTE: In addition to the fee, assurance for the public improvement is required in the amount of
100%of estimated public improvement cost.
PFI Permit Fee Exemptions:
Although a permit is required, there will be no permit fee charged or assurance required for the following types of
work:
• Sidewalk repair(less than 20 lineal feet)
• Curb repair or replacement(less than 20 lineal feet)
• Driveway repair
• Relocate or replace mailbox
• Ditch cleaning that does not involve regrading.
• Weephole repair
• Lawn sprinkler system installation or repair
• Street tree pruning or planting
• Planter strip landscape maintenance
• Test wells
Additional exemptions may be granted upon written request, subject to review and approval by the City Engineer.
2. Addressing Fee: The fee for this service is$50.00 per address.
SAMPLE
Minimum Sketch Requirements
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 of Pavement Trees
Existing S/W or D/W Apron Existing Utility Locations(sewer,water, storm)
SAMPLE SKETCH:
SW Y
Edge.of P avemeht
-#— Ditch —�
Streetlight I -- ------ — —r— —
I e
� I ! &1t Trce � a
o e a 1
propowerTine--
Existing House
Existing 1
IDriveway
'' I 1
Ci ^ LOI
QI
0 I '
1
o� 1
( Existing Shop. i
Powerpole I I I a
--------76'p pLi—ne----------
Ia I Fire Hydrant(FH)
I i I
Scale: 'I"=30'
� I I
� I I
' I I
� I �
Minimum Sketch Requirements (Put "n/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 of Pavement Trees
Existing S/W or DIW Apron Existing Utility Locations(sewer,water,storm)
SKETCH AREA:
i\eng\privEeNeppl—tions\p(i application(2)doc
/ Construction Notes:
I' I 1.CAUTION:Facilities shown on this plan were obuinedhom rcmrds
CONTACTS: and/or visual surface inspection
2.some facilities may be omitted,or shown at an incorrect location.Exact
OSP Const:PJ Fellows 503-519-3445 Q location of all facilities must be determined prior to start of construction.
3.All materials,methods of placement and restoration must most the
reqSPVC Tech Ops Mgr:Jeff Steltenpohl 503-679-1033 Q Construction
must y of
0.Construction must replace and restore any landscaped arca disturbed
Facil Tech:Corky Belanger 503-643-0181 during const ruction back to its original or better then condition
5.Contractor is to place all new UG facilities per work plan,Contractor will
OSP Inspct:Bill LaFleur 503-936-2035 need to notify the area Frontier Inspector and-the engineer for making
any additional field changes
x-
12517 SW 123RD AVE.
TERM 69175
TGRDORXC H2O269
33-34+201-202
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BO E 45' 1.25" SUB UCT j W S
123RD FACING NORTH
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PERMIT SKETCH
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12517 SW 123RD AVE.
PROJECT C.O.AREA BLMT
% MEER: EXCH.CO
DRAWN DATE. I ENGR' SALBERT rNTY WASHINGTON
428/16 PHONE, 503-5263544 FILE
SCALE:1=50 1 TAX DISTRICT: DWG 1 OF 1
TWNSHP. IRNG SEC