PFI2016-00244 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12016-00244
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 11/09/2016
Parcel: SEG934
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: PGE
Project Description: Remove pole, UG existing OH/H DDR
Owner: FEES
Description Date Amount
PFI Permit Fee 11/08/2016 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
CHRIS JEWETT
10800 SW AVERY ST
TUALATIN, OR 97062
PHONE 503-672-5481
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:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12016-00244
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. Ken fisher 503-816-6146 or Kenny@tigard-or.gov
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
RECEIVE®
City of Tigard NOV 0 2 2016
PUBLIC:WORKS —ENGINEERING CITY OF TIGARD
. PLANNING/ENGINEERING
Public Facib t y. Tmpro ern.en.t OTT) fermi
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-quay)
TYPE 1—Franchise LtiLiw 10�'ork
Check one: Vlitilities ❑Sidewalk/dri,eway approach ❑Strectirnprovemenu performed bY NkyW. PGE
Detailed description: PGE JOB M2190476 and/or utility agency.
REMOVE POLE, UG EXISTING O/H - DDR ❑ TYPE 2-Sidewalk/Driveway/:ewer
Work performed for the purpose of:
• Sidewalk installation or repair.
• Driveway approach installation
Property address/locadon(s): 3 and/or repair
12115 SW 70TH AVE, TIGARD, OR 97223 • SaniWv sewer lateral installation
and/or main line tap
Applicant: Portland General Electric ❑ TYPE 3—Full scale Development
pp Fork performed with Land use
Address: 10800 SW Avery St. approval which includes any of
Cita=/state: Tualatin, OR zip: 97062 the following:
Phone: 503-672-5481 Email: PreregCoord@pgn.com • Subdivisions or Partitions
Contact name: Phone: 503-672-5481 e Streetwidening
;Mainline installation for Sanitary
N/A sewer, Storm sewer,Tigard water
Contractor: and/or Tigard Water Service Area
CCB#: Expiration:
Address: SUBMIT COMPLETED APPLICATION TO:
City/state: Zip: City of Tigard
Phone: Email: Planning/Engineering
13125 SW Hall Blvd.
Contact name: Phone: Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: C H R I S J EW ETT only may be emailed to:
Address: 10800 SW Avery St. rQpertnits0&.Qard-or.gov
City/state: Tualatin, OR Zip: 97062
Phone: 503-672-5481 Email:PreregCoord _,pan.com Case ,�FIao�G�o: Q'b2
Contact name: Application submittal fee: #'3vo•va
Additional fees:
Estimated value of work is required(if over$5,000):$ Application accepted: /
(within the public right-of-way) By: Date:
Application reviewed:
Is work related to a LAND-USE DECISION? ❑ Yes ' N`0 11_ >8 _1(y
Applicant notified:If so,please specify(MLP,SDR,SUB,etc.) case#: '`` St�if2— Date:
Aped:
,� /s ii
Is work related to a BUILDING PERMIT? ❑ 1Y//e< No By: Date:
I1 so,please specify(BUILDING PERMIT)case#: \CUAPLN\Masters\Land Use AppllcaWns Rev.09/26/2016
City of Tigard a 13125 SW Hall Blvd. a Tigard,Oregon 97223 a ununetigard-or gov a 503-718-2421 a Page 1 of 4
APPLICANTS
NOTE: Person specified as Applicant"shall be designated"Permittec",and shalt provide financial assurance for work,if
required by the city pursuant to"I"MC 15.041.140.
' \?id:the txccptic»;of a utihtc of>etanr�a�vlru]n+to a valid&anehik•ttith the Citti'of•fivard,when thr owner ani this applicant arc'different
peopic,theapplicaw mus;be the putc1m;ci:(if record r:i lesm in pos'ession with written ludionzation from the owner car an agent of the
i'he owner,' inUlt tgr thi�apphuttion 10 the spice pro6ded )r submit a wtitteii audion/.ation vith dii.,application. Nand ,
owner. V1. lised
Utilities arc riot required to obtain the ownet',,signanire on the application
BY SIGNING BELOW,THP:APPLICANT(S)SHALL CERTIFY THAT:
• 't'he above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject
Ingver .
• If the application is granted,the applicant will exercise the nights,granted in accordance with the terms and subject to an the
conditions and limitations of the approval.
• All of the above statements and the statements in any 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.
Brian Moore �L\v,
Applicant/AuthInized Agent's signature Print name
Date
SIGNATURES of each wwner of the subject property,if required.
Owner's signature Print name Date
Owner's signature Print name Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City ofTigard • 13125,9WHall Blvd • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2421 • Page 2of4
DEVELOPMENT ENGINEERING FEES FOR STAFF USE ONLY
Public Facility Improvement(PFI)Permit:
DETAILE D SUBMITTAL
L T
APPLICATION FEE REQ IREMENTS
Part 1: Requited�,ulirnittal fee$300.00 FRANCHISE 1JTIIJTY AND SIDEWALK/
PERMIT FEE DRIVEWAY AND UTILITY
CONNECTIONS,ETC.
Part 2: .:111 non-water system improvements
fl'tigine&s estimate X 5%(less$300.00 submittal fee) ("ork in the right of way)
Engineex's estimate X 2%' Plan Review Sketch
(including in formation below)
NATER SYSTEM FEE El Dimensions
Part 3: All public water system improvements El Street Name
Engineer's estimate X 12% 0 Site Address
PFI Permit Fee Exemptions: FULL SCALE DEVELOPMENT
There will be no permit fee charged,or assurance required
for the following types of work: (-SLtbdivisions/11-artit.-to-.is and Street Improvements)
• Sidewaht repair(less than 20 lineal feet) Design Plans
• Relocate or replace mailbox (6 sets,24x36 or 22x34)
• Ditch cl=ung that does not involve regrading.
• Weep hole repair 0 Cover—Site,Vicinity,Abbreviation,Legend
• Curb repair or replacement(less than 20 lineal feet) El General Notes(City,Water,Sewer,etc.)
• Lawn sprinkler system installation or repair 0 Street(Plan,Profile)
• Street tree pruning or planting El Water,Storm and Sanitary(Plan Profile)
• Planter strip landscape maintenance 0 Water Quality Facilities
• Test wells 0 Grading
1:1 Landscaping/Tree Plan
El Composite Utility Plan(Electrical,Phone,Gas,
Note.- A cash assurance may be required per Storm,Sanitary,Water,Signage,Street Lights,etc)
TMC 15.04.140.(customer deposit) 0 Details
0 Traffic Sight Distance
0 Signing and Striping
0 Street Light Plan and Photometric
0 Engineers seal/signature
El Sheet label(project land use name,revision and
plan log block,dates and sheet numbers.)
Additional Submittals
(per Land Use conditions)
D Traffic Report
0 Storm water Drainage Calculations
F-1 Geotechnical Report
0 Preliminary Access Report(Sight Distance)
0 Proposed Plat
El Pathway Design(if applicable)
El Water Department Approval
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard 13125 SW hall Blvd. - Tigard,Oregon 97223 - wwwtigard-or.gov .503-718-2421 - Page 3 of 4
SAMPLE SKE'T'CH::
I . _
Edge of Pavement
Ditch 0"
Streetlight -—-—-—---•—- --r-----
plin
D
' T`�roj�as crSow'erTine"
.0 r 1
Nr Existing House
�� ( Existing 1
yI Driveway
511 I 1
1
CLL 011
>
I j
0 1
Exiling Shop
Powerpole I I = a
'�----•--Trop7iLne-------i---
i
Fire Hydrant(FH)
i I
Scale: 'I"=30'
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 "frees
Existing S/W or of pavement Existing utility locations
D/W apron (sewer,water,stonn)
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard 13125 S%X'1fall Bhd. • Tigard,Oregon 97223 • wwwtigard-or.gov 503-718-2421 Page 4 of 4
WL1:
Instal:
SU4288-CAPS,ENTRANCE,3'.CLAMP
423-3-IN PVC CO 'ND UNIT W/12BKTS
WL 1-2 Span:
(99)646-1-RUN OF#2 TX,AL NEUT 2 121
7105 WR CHECKLIST
7155 7085
ITEM YES COMMENT
WL2:
HOLEDIGGER X
663-POLE,DISTRIBUTION 35.
POLE#125 C21-01A BOOM
PGE OWNED POLE,TOP TO COMMS BACKHOE
4
1577 45' PGE TRENCH
4S< 95
2014
LOCATES
A 25 70763 STAKING
AN CU '__.__
__ _.. -A410AL TX-- WE 1-3 Span: FLAGGING
X
C2 I-01A nstall TREETRIM
(265)494-i-RUN OF 4/0 AL URO TX
Preinstalled b Customer
LANDSCAPE
SW EL RST ST (190)4-SCHED 40 PVC W/FIBERGLASS SWEEPS EASEMENT
PERMITS
TRAFFIC PLA X
CUTSHEET
UG CIR,VER.
TRANSMISSION
SHUTDOWN
7130
C
-- 7100 7070 7040 12259 CUSTOMER X 7040 ELMHURST
SHUTDOWN
WE 3:
- - Install: DOOR HANGER
-
BANK-S—i'Point CONTACT
MT2005740-METER,FORM 02S.4-JAW,AMI COMPANY
0 20 40 80 Feet PH# C#
I I I I I I I I I
PGE 10ATE TIME
PGE CONSTRUCTION DRAWING
AS-BUILT VERIF7 A N.8..N.ES VIOLATIONS CORRECTED
Vicinity Map
Foreman: Date.
General Foreman: Date:
lSi Y mly rt"—d M held consbud than sJ
SDPMIENG REVIEW SBUILT BY DESIGNER:
... DATESCALE ACCOUNT AWO JOB NO
r 11/1/2016 1070001 1000004546 M2190476
TITLE
7040 Southwest ATTENTION: CALL 811 BEFORE YOU DIG CH PHYSICAL THERAPY LLC
Elmhurst Street OREGON LAW REQUIRES YOU TO FOLLOW RULES ADOPTED / CI CUT S11
BY THE OREGON UTILITY NOTIFICATION CENTER. j WEST PORTLAND-WEST PORTLAND 13 11 x 17
THOSE RULES ARE SET FORTH IN OAR 951-001-0010 1I P� , LOCATION
TDNK THROUGH 952.001-0090 YOU MAY OBTAIN COPIES OF `E!/J12115 SW 70TH AVE TIGARD
THE RULES BY CALLING THE OREGON UTILITY ON
SNOTIFICATION CENTER ADMINISTRATION@(502-132-1987) 5 REMOVE POLE,UG EXISTING O/H-DDR SHEET
TO REQUEST UTILITY LOCATES CALL THE OREGON Know what's below. COUN WORK KI H
trk F UTILITY NOTIFICATION CENTER,811 AT LEAST Call b0ore YDU dig. DESIGNSY PHONE WASHINGTON C21-01A OF
AWN BY
lire _ 2 BUSINESS DAYS PRIOR TO EXCAVATION CHRIS JEWETT 672.54811 CCH S JEWETT
O PORTLAND GENERAL ELECTRIC CO.-ALL RIGHTS RESERVED
2011 Edition Page 85
Stationary Lane Closure with Flagging Diagram 320
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Sign Spacing and Buffer Lengths(feet) w
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S acin Between Signs Buffer W p
A 8 C Space zo¢=d O
50
100 100100 75
100
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350 350 350 150 O O
45 180 Q 3
50 500 500 500 210
55 250
December 2011 Chapter 5