PFI2017-00015 RECEIVED
City of Tigard
V0 I FEB 0 2 2017
PUBLIC WORKS — ENGINEERING
CITY OF TIGARD
Public Facility Improvement (PFI) NTMYIGIIEERIIG
TIGARD —
DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL
Check one: N Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS
Detailed description: bCCESS MANHOLE TO SPLICE FIBER OPTIC N Minor work in right-of-way
(sidewalk repair,curb cut,street
CABLE TO PROVIDE SERVICE TO CUSTOMER LOCATED AT 8015 SW opening,etc.)requires:
HUNZIKER STREET. •Application form,completed
and signed
•Submit one(1)copy of scaled sketch
Property address/location(s): 8015 SW HUNZIKER ST. of the proposed work to be done
•Submit one(1)copy of traffic
control plan
—OR—
El Substantial project work requires
Applicant's name: Frontier Communications /Scott Albert above items and professional
Address: 4155 SW Cedar Hills Blvd. engineered plans for:
•Street widening
City/state: Beaverton Zip: 97005 •Subdivision infrastructure
Phone: 503-526-3544 Email: scott.albert(a7ftr.com •Main utility line extension:
- Storm Drain,Sanitary—Tigard
- Water—Tigard Water Service
Contractor's name: Sonicom Area(includes Durham,King City
CCB#: 188116 Expiration: 9/24/2017 and a portion of unincorporated
Address: 1275 S Kodiak Circle Washington County)
City/state: Cornelius Zip: 97113 DELIVER APPLICATION TO:
City of Tigard
Phone:503-710-2972 Email:mattshore(@sonicom.com Planning/Engineering
13125 SW Hall Blvd.
Engineer's name: Scott Albert Tigard,OR 97223
Applications for"minor work in right-of-way"
Address: 4155 SW Cedar Hills Blvd. only may be emailed to:
City/state: Beaverton Zip: 97005 ro ermits .tigard-or ggv
Phone: 503-526-3544 Email: seott.albert(a_ftr.com
Estimated value of work (within the public right-of-way): $2,000 Case No.:?F1S0 r1^0Cx>1
Application submittal fee:
Is work related to a LAND-USE DECISION? ❑ Yes N No Application accepted:
If so,please specify (MLP, SDR, SUB, etc.) case #: By: 2w�== Date:? �
Is work related to a BUILDING PERMIT? ElYes ® No Application reviewed:
If so,please specify(BUILDING PERMIT)case#: By: Date:
Applicant notified:
By: Date:
I:\CURPLN\Masten\land Use Appliutfons Rev.07/16/2014
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 1 of 4
City of Tigard - COMMUNITY DEVELOPMENT DEPARTMENT V
Request for Permit Action � /2
• 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard, OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ® City Staff
Check(✓)one
REFUND OR Name: N/A
INVOICE TO: (Business or Individual)
Mailing Address: N/A
City/State/Zip: N/A
Phone No.: N/A
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓):
(aCANCEL VOID PERMIT APPLICATION.
-RPERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: PFI2017-00015
Site Address or Parcel#: SEG1151
Project Name: Frontier Communications
Subdivision Name: N/A Lot#: N/A
EXPLANATION: Segment is actually under ODOT's jurisdiction, not City of Tigard's.
Date: 2/2/17
Signature: --1-
Print Name: Lina Stnith
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
FOR OFFICE USE ONLY
Route to Sys Admin: Date B Route to Records: Date a s / B
Refund Processed: I Date /v t B Invoice Processed: Date B
Permit Canceled: I Date /7 B Parcel Tag Added: Date B
I:\Building\Forms\RegPermitAction_ 23 4doc
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(q)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 Apert;.
• 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.
_Omo Scott Albert 02/02/17
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:
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 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
51351-WO485559
TGRD-FES-PCI PORTLAND INTERIORS :227 2
FC227,1-24+ RBN 24
8015 SW HUNZIKER ST. m / X11,2528+ 0227,25-26+
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= FC227,1-24+ FC227,27-28+ CONTACT ARS MQU�BEO WPpV
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AT MH 52 PLEASE ADD COUNT FC227:29 TO EXISTING COUNT FC227 30-48 X( D,9-24) CREW DP. U X-TIME 0
0227,25-26+ SPLICING ! 0 0
FEEDING EXISTING FIBER TERMINAL. PLEASE SEE ATTACHED FC227:25-26+ NQ DRIVER
❑FTTP GROWTH -OMAs BROS.
DOCUMENTATION. 4/52 FC227,27.28+ ❑FTTP OVERLAY
ACCESS FC227,27-28+ 10 FIBER
❑CONDUIT ONLY
CUSTOMER CONTACT: JAKE MANUS- 913-310-3504 MANHOLE HERE. o� FC227,29+ ONSTRUCTION START 2/1/17
FC227,29+ IN SERVICE DATE
v XD 11-24 cors TRUCTION COMPLETE
CONTACTS: 2Ov
rCUTS REQUIREp
ENGINEERING SPLICING/PLACING Sh y� (� M YES ❑No CONSTRUCTION
SCOTT ALBERT JOHN GAYLORD y2/� JOINT TRENCH ❑DIAL. A DIG
503-526-3544 503-476-5805 FQy
MI-15153 JOINT
YES M No M FLAGGING
FACILITIES PLANNING O ❑BRUSNING
MICHELE CRISMAN LYN STEICHEN YGD 48 p Yes REQ No C3CIONQTRDACTING
503-643-0180 503-626-3156 FC227,1-48
INSPECTOR OPCEN PERMITS
BILL LaFLEUR RYAN ROBERTS MUNICIPALITY CITY OF TIGARD
503-936-2035 503-643-3713 SS 306 1 MUNICIPALITY
BBGTD 2,601-900 ❑ BLANKET
TCP/TRAFFIC
S I = VICINITY MAP QY� 0 DETAILED (NOT BLANKET)
CR:+ NO PERMIT REQUIRED
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JOINT POLE
JFN/NJUNB ,WA
CUSTOMER JFN/NJUNS / NIA
S(.y01 I 661 PCI PORTLAND INTERIORS 0➢No JeN REQUIRED
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NST N m o / ❑ ❑ ❑ PowER
❑ ❑ ❑ CATV
TIC PANEL 249502 13 ❑ E3 FRONTIER
FC227,25-26+
POINT OF CONTACT
FC227,27-28+ SCOTT ALBERT
MI-17/54XD,9-24 5113-526-3544
0
FC227,25-26+ SCHEDULING RYAN ROBERTS
�\ _ 1 F(.`22 PHONE N0. SCOTT ALBS
ENGINEER SCOTT ALBERT
C-1' 1 PHONE NO.(503)5263544
p�\ ¢ I FC227,25-26+I
1 1 / FC227,27-28+ TECH, LYN STEICHEN
ND
3)626-3156
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PROJECT
NUMBER:W0485559 EXOCM CODE 51351
1= DRAWN DATE'. ENGR. SALBERT NTY.WASHINGTON
02/01/17 PHONE. 503-526-3544 FILE.
Y\ a SCALE:1=1D0 TAX DISTRICT DWG 1 OF 2
TWNSHP'2S RNG 1W SEC 18
51351 -W0485559
8015 SW HUNZIKER ST.
2011 Edition Page 109
Right Lane Closure, Multi-Lane Non-Freeway Diag. 500
1 1
I T T SW HALL BLVD.
H4/52
Protection Vehicle
NORTH W�$e�o er Optional)
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ROAD
WORK
AHEAD
FRONTIER CONTACT
1.OSP CONSTRUCTION MANAGER: DAVID DODD 503.848.3283
2.OSP ENGINEER: SCOTT ALBERT: 503.526.3544
3 OSP INSPECTOR: BILL LAFLEUR 503.936.2035
4.OSP ENG & CONST MGR: PETE CALO 503.526.0357
December 2011 Chapter 5
51351 -W0485559
8015 SW H U NZI KE R ST.
Page 110 2011 Edition
Interior Lane Closure, Multi-Lane Non-Freeway Diag. 510
Diagram 510 covers work which will block the left lane(s)of a multi-lane non-
freeway road.
1. Use truck-mounted flashing warning lights on work and protection
vehicles. See Section 4.3—Lights and Lighted Signs for exceptions.
2. For added visibility, a truck-mounted arrow board or PCMS in caution
mode may be used.
3. If the adjacent lane in the opposing direction is not closed, cone off the
work space placing the cones in the median or along the centerline if
there is one.
4. Placement of signs in a non traversable median or other median that is
not a two-way left turn lane is required for lane closures any time there
is room for a truck to be parked on the left, out of the travel lane.
When there is no room for a truck to be parked on the left an additional
LEFT LANE CLOSED AHEAD sign should be placed on the right side
and placement of signs in the median is optional.
5. When the posted speed is 40 mph or less, the LEFT LANE CLOSED
AHEAD signs may be omitted.
6. Cones may be placed as shown on centerline in advance of the work
to better gain the attention of motorists.
7. Work vehicle(s)with or without a TMA may be used to protect the
workers and work space.
Sign Spacing and Buffer Lengths(feet)
Posted S acin Between Signs Buffer
Speed A B C Space
20 50
25 100 100 100 75
30 100
45
350 350 350 125
150
45 180
50 500 500 500 210
55 250
Chapter 5 December 2011