PFI2016-00098 `y �t CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12016-00098
R 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 06/06/2016
Parcel: SEG2468
Jurisdiction:
Site address:
Subdivision: Lot:
Project: PGE Replace cross am on Pole 3113
Project Description: PGE Replace double cross arm on Pole 3113
Owner: FEES
Description Date Amount
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
MIKE CARSTEN
10800 SW AVERY ST
TUALATIN,OR 97062
PHONE: 503-310-7784
Total $0.00
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 PF12016-00098
Type: Condition Name: Status: Severity:
PFI_Utilities 01 -WORK SITE REQUIREMENTS 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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.
PFI_Utilities 18-PERMIT/PLAN ON SITE 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 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 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 Notice
7r City of Tigard RECEIVED
PUBLIC WORKS —ENGINEERING PGE WORK ORDER# M20 2s 7 2016
IGARD
T,GAR
Public Facility Improvement (PFI) VSfi"GINEERING
DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL
Check one: IM Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS
Minor work in right-of-way
Replace double cross arm on Pole 3113 8
Detailed description: p (sidewalk repair,curb cut,street
opening,etc.)requires:
•Application form,completed
and signed
•Submit one(1)copy of scaled sketch
Property address/location(s): 7382 SW Bonita Rd of the proposed work to be done
SC-C-1 2-4(O Q •Submit one(1)copy of traffic
V control plan
—OR—
Mike Carsten / Rachel Schoenheider ❑ Substantial project work requires
Applicant's name: above items and professional
Address: 10800 SW Avery St engineered plans for:
City/state: Tualatin, OR Zip: 97062 •Street widening
•Subdivision infrastructure
Phone: 5503-310-7784 Email: T&DSupportAvery@pgn.com •Main utility line extension:
Storm Drain,Sanitary-Tigard
Water-Tigard Water Service
Contractor's name: 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.
Engineers name: Tigard,OR 97223
Applications for"minor work in right-of-way"
Address: only may be emailed to:
City/state: Zip: rownermitsktigard-oLgay
Phone: Email:
Estimated value of work (within the public right-of-way): $$1,095.31 �`
Case No.: K:z w 110 coo
Application submittal fee:
-
Is work related to a LAND-USE DECISION? ❑ Yes p No Application accepted:
If so,please specify (MLP, SDR,SUB, etc.) case #: By: M 6 Date:
Is work related to a BUILDING PERMIT? ❑ les 8 No Application reviewed:
If so,please specify(BUILDING PERMIT)case#: By:.Ow Date: Zz'x_�
Applicant notified:
By: L S Date: 61&11(e
I:\CURPIN\Masten\lsnd Use Applintlons Rev,07/16/2010
Cityof Tigard • 13125 SW Hall Blvd. - Tigard,Oregon 97223 - www.tigard-or.gov - 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 APPLICANT(S) SHALL CERTIFY THAT:
• The above request does not violate any deed restrictions that may be attached to or imposed upon the subject propel
• 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.
09b,Vy igr by a,a Sdro°�,
DN Rachel Schoenheider : �°""'-W..C— °°°�re` Rachel Schoenheider 05/16/16
Electro,°u.Prereyuiub Ca°rtlm,hon,
Dmeal-Re—SanoonnoM @nn...,c-U9
ere zme os ie n oe m mm•
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
• Plantcr 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:
sw „ s1
Edge of Pavement
I -OW Ditch —�
Streetlight ----------------
Rain
I — —•—•—•—•—•— —Raaf Dna.
SIP,
' T--riopos W"70 eiiTiiie"
I 1
I u
Existing House
Existing 1
yr Driveway
a�
011
C- w
01
O�
I
o�
I 1
Existing Shop �
Powerle I I
0 0
--—-—-—-Frop rtey ine-—-----—---
� I R
I I
Fire Hydrant
irHydrant(FH)
� � I
Scale: 'I"=30'
� I I
I I
� I I
i � I
MINIMUM SKETCH REQUIREMENTS (Put'IN/A" if Not Applicable):
X North arrow NIA Property lines &dimension NSA Slope of property
X Street& street name(s) NSA Existing building, structures X Utility& street light poles
X Proposed work N/A Existing curb or edge NSA Trees
N/A Existing S/W or of pavement NIA 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
OVERHEAD LEGEND
AK 300121E � REMOVE FACILITIES INSTALL FACILITIES
INSTALL ADDITIONAL FACILITIES/MODIFY FACILITIES
.-x k-DB J] Po 0000]
A u E7266 A m 67173 ,w
30 SGL DE, FIBERGLASS 8', POLY
SW 80NIT"RD - - - — nail Dose �I)
7261 0 1—
I-.o - nc ,xaoA oe•� Po Dom] '
� xoo� yr coos, '1
7260 A 23 SM74
Po m,s] f .. —1 -ve C SO 344W
7262 R "-„-
A 30 33884 o ANY DEVIATION FROM THIS DESIGN MUST
3 -
C 30 331997 BE APPROVED BY PGE PROJECT MANAGER
63w .o RIGHT-OF-WAY PERMIT NOTICE:
S A PERMIT FORM THE LOCAL JURISDICTION IS REQUIRED BEFORE ANY
WORK IN THE RIGHT-OF-WAY MAYBE PERFORMED. ONLY PGE APPROVED
CONTRACTORS AND CONTRACTORS WHO HAVE MADE OTHER SPECIAL
AGREEMENTS WITH PGE WILL BE ALLOWED TO WORK UNDER PGE'S PERMIT.
F.. THE CONTRACTOR MUST NOTIFY THE LOCAL JURISDICTION 48 HOURS
9 25 X10 WR CHECKLIST BEFORE WORK IS TO BEGIN. A COPY OF THE PERMIT MUST BE ON SITE.
1 A 25 26313
ITEM YES COMMENT
HOLEDIGGER
ATTENTION CALL 811 BEFORE YOU DIG
- ,
OREGON LAW REQUIRES YOU TO FOLLOW RULES ADOPTED
BOOM THINK BY THE OREGON UTILITY NOTIFICA TION CENTER ,
P L-3113 BACKHOE THOSE RULES ARE SET FORTH IN OAR 952-001-0010
SAFETY THROUGH 952-001 0090. YOU MAY OBTAIN COPIES OF
REPLACE DOUBLE X-ARM HEAVY WITH: PGE TRENCH - THE RULES BYCALLING THE OREGON UTILITY
FIRST! NOTIFICATION CENTER ADMINISTRATION®(503-232-1987)
o.
D Z7 TO REOUEST UTILITY LOCATES,CALL THE OREGOt.
UTILITY NOTIFICATION CENTER,811ATLEAST KnO Call before
you
LOCATES Call before ou tli
:-eUsrdEssoavapu�nuro=x^a/4 PON
Y 9�
RESPONSIBLE PARTY:PGE STAKING PGE CONSTRUCTION DRAWING
JOB S11 t FLAGGING x SDP"ENG REVIEW I AS-BUILT BY DESIGNER:
TREE TRIM AS-BUILT VERIFICATION&NESC VIOLATIONS CORRECTED
LANDSCAPE This oo,:.. )accurately represents FIELD construcl,u.
b EASEMENT - Foreman: Date:
PERMITSX CITY OF TIGARD GF' Date:
TRAFFIC PLAN X NWTCI °ATE 0510312016 scA" 1.125 ACCOUNT 5930001 "� 3000000850 roe No M2042423
CUTSHEET - TITLE
I WFIB PL-3113 GUYING UPGRADE
UG CIR.VER. - CIRCUIT s,zF
U TRANSMISSION \ DURHAM-SATTLER 11 X 17
m o SHUTDOWN CUSTOMER PGE
VG/p^C LDcarroN.
7382 SW BONITA ROAD,TIGARD
SHUTDOWN DEscalvnoN
DOOR HANGER - WFIB PL3113 GUYING UPGRADE
CONTACT COUNTY SECTIONS/' WORK WITa SHEET
COMPANY
VICINITY MAP WILSONVILLE WASHINGTON C21-12A - OF I
DESIGN 8Y PIgNE DRAWN eY
LINE CENTER
THOMAS GUIDE: 655-G6 PH# C# 9180SWBOECKAfANRD.MIKECARSTEN #503.310-7784 HEIDI BOOMER
WILSONVILLE.OR 97070
DATE TIME 0 PORTLAND GENERAL ELECTRIC CO.-ALLRIGHTS RESERVED