PFI2016-00168 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
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Request for Permit Action 0211
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • \t-,,vw.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:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓):
CANCEL/T ID PERMIT APPLICATION.
—'R' PERMIT 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#: T -F1201(p —00((08
Site Address or Parcel#: �
Project Name: �(,(�i�Ot'�1 h V Ql �it/� �pE-�(/1' D wS )&t
Subdivision Name: Lot#:
EXPLANATION: Dads%Cotte aCXrn�,t: Work- dor�.e L,�y� lr
�l 201 lo-c�I to 3
Signature: Date: 'j (co
Print Name: CS z-owGt C 2–
Refund
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 S s Admin: Date Bti Route to Records: I Date
Refund Processed: Date N By Invoice Processed: Date B
Permit Canceled: Date /(o / B Parcel Tag Added: Date B37
I:\Building\Forms\RegPermitAction_ 923 4.doc
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CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
s
COMMUNITY DEVELOPMENT Permit#: PF12016-00168
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 08/08/2016
Parcel: SEG249
Jurisdiction: Tigard
Site address:
Subdivision: Lot: V
Project: Tualatin Valley Water District
Project Description: 4"and 6"DIP crossing Lincoln St. and 4"meter vault installation in sidewalk.
Owner: FEES
Description Date Amount
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
JAVIER MONCADA
1850 SW 170TH AVE
BEAVERTON,OR 97003
PHONE: 503-848-3091
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
�—�of P
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12016-00168
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
V 0 1 0 RECEIVED
AUG 04 2016
City of Tigard ,/ CITY OF TIGARD
PUBLIC WORKS—ENGINEERING PLANNING/ENGINEERING
Public Facility Improvement (PFI) Permit
DESCRIPTION OF WORK(in the right-of-way) TYPE OF WORK
Check one: ,2rUtibry Connection TYPE 1-Franchise Utility Work
❑ Sidewalk/driveway approach Work performed by NWN,PGE
❑ Street improvements and/or utility agency.
Detailed description: �1f PND (oma DC_C, ❑ TYPE 2-Sidewalk/Driveway/Sewer
L;N t Lw S_t R- T /kew b "%* METEA- u1. lt- Work performed for the purpose of:
1 NS7/tLL/t T�o N t Q S ipE W p.t_V[- • Sidewalk installation or repair.
S' ^� - Driveway approach installation
LINevLN S� FL1=ET UtJ and/or repair
Property address/location(s): • Sanitary sewer lateral installation
Ertl E.T E� El_E M1=-ivZh 4"h U-- and/or main line tap
❑ TYPE 3-Full scale Development
Applicant: 1'vh"'%'%ty 1/ItLLEy W k �'�sT�`� Work performed with Land use
Address: approval which includes any of
the following:
City/state: 6r-A%jU t o N 0,5L- Zip: 1)4—3 • Subdivisions or Partitions
Phone:5i; 14K 105% Email: 1o^Vid-t . Uk0n(.-'3-►e `}y.a�.or•� - Street widening
Contact name: M u Wt_►-%A Phone: - Mainline installation for Sanitary
sewer,Storm sewer,Tigard water
Contractor: S \,,-• and/ot Tigard Water Service Area
CCB#: k 0Q 1 S} Expiration: SUBMIT COMPLETED APPLICATION TO:
Address: %I SP Z- 'b �NS-E� P"E City of Tigard
City/state: Of— Zip: cl-7k oo Planning/Engineering
Phone:5o3_+a6-Sa2 BA Email: 13125 SW Hall Blvd.
Tigard,OR 97223
Contact name: _!�JAA KAl V,%"i N Phone: Applications for"minor work in right-of-way"
only may be emailed to:
Engineer: Q AW s Ewa ASN 4r,R L t-. [ownertnits(&1ti�ard�r.Qov
Address: 215 w IN
City/state: \J"L o-— I ^ Zip: Cis W.-
Phone:3W°- r s i-`I tbs Email: Case No.: I-/92C21(0
Contact name: Nk'T*1A" A q �=C LcZ hN fz Application submittal fee 300.eC
Additional fees:
Estimated value of work is required(if over$5,000):$ Application accepted:
(within the public right-of-way) By _ , Dare:
Application reviewed:
Is work related to a LAND-USE DECISION? ❑ Yes No ,l• SIE
If so,please specify (MLP,SDR,SUB,etc.) case#: Br Darr:
Applicant notified: Q
Is work related to a BUILDING PERMIT? N Yes ❑ No By: � Dare: U�
If so,please specify(BUILDING PERMIT)case#: ?LVA lollo-boo$Z I:\CURPIN\Mesters\land Use Apokations Rev 07/09/20I5
City of Tigard - 13125 SW Hall Blvd. - Tigard,Oregon 97223 w\vwtigard-or.gov - 503-718-2421 - Page I 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 inpoxcd upon the subject pro cry.
• 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.
k -TA NJ lEf- �. j►n OtJ IL-kaA
\P G t/A thorized Agent's signature Print name Date
Owner's signature Print name Date
Owners signature Print name Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov 503-718-2421 • Page 2 of 4
1 4 5 6 7 8
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1. EXISTING PIPE AND METER SIZES FOR CONNECTIONS 5, 6, AND 7 ON THIS SHEET ARE ASSUMED. I C M 1 ( I �Qik
tD CONTRACTOR SIMII POTHOLE EXISTING POTABLE AND FIRE SUPPLY PIPING AT THESE LOCATIONS
3 AHEAD DF TIME TO DETERMINE MATERIALS NECESSARY TO CONNECT TO EXISTING SYSTEM. I t I I I 1842P r A
COORDINATE SERVICE INTERRUPTIONS WITH TVWD AND SHORENSTEIN. WORK SHALL TAKE PLACE AT --
N NIGHT OR DURING THE WEEKEND.
c 2. EXISTING WATER METERS MAY BE EQUIPPED WITH BYPASS PIPING. IF PRESENT, CONTRACTOR TO - - -----` R E(;O N
E RECONNECT.
4. ALL IN PIPE, VALVES,AND FITTINGS SHALL BE POLYETHYLENE ENCASED AND ALL JOINTS SHALL t
E BE BONDED.ALL DI PIPE, VALVES,AND FITTINGS SHALL BE PROTECTED AGAINST CORROSION WITH 8 METER AND BACKFLOW ASSEMBLY EAST
GALVANIC ANODES. SEE GENERAL NOTE 2, SHEET C2.
3 5. ALL PE, VALVES, AND FITTINGS SHALL BE MECHANICALLY RESTRAINED. EXPIRES: 06/30/2016
v
D°NE,. '_ LINCOLN CENTER WATER MAIN DATE OS�2011i
M0�I� SCALL EpallisTualatin Valle Water District PROJECT N0
,ala, y REPLACEMENT PROJECT 1365A
s s F ,t a ACCT. NO. 012429
0 DRAWN: CCK DATE: 05/16 � .. .It I ',..r i .,,.
DESIGNED: NEA DATE: 05/16 6: C - 4; \� CONNECTION DETAILS II SHEET NO. 11 OF 21
215 W 4th Street.Sud%200
REV DESCRIPTION BY DATE CHK'D APPR APPROVE: WMW DATE: 05/16 Vancouver.WA 98660
a 1850 SW 170d1 Ave., Beaverton,OR 97003 (503)84&3000 www.tvwd.org DWG No.
REVISIONS APPROVED.RCw DATE: 05/16 C1 1
2 3 4 5 6 7
VALVE AND FITTING SCHEDULE
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224 23+OD
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SCALE I. C14 C14 4 �4 REMOVAL W1 INSPECTOR PRIOR TO
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KEY NOTES
'i DI WATER MAN
Lc [A CONTRACTOR TO HIRE PRIVATE UTILITY LOCATOR,
PROPERTY OWNER PRIVATE PROPERTY OWNED BY SHORENSTEIN PROPERTIES LLC, SEE 1 CITY OF TIGARD RIGHT—OF—WAY SEE NOTE 1, SHEET C2.
i2
0 220 220 IT]ALL WATERNE ENCASEDMAIN. VALVES,AND FITTINGS SHALL BE
POLYETHYLE , HAVE JOINTS BONDED, MO
o BE PROTECTED BY GALVANIC MODES, SEE GENERAL
NOTE 2, SHEET C2.
REMOVE EXISTING METER AND VAULT,ATTACH TO
DUSTING POTABLE SUPPLY PIPING. EXISTING POTABLE B
SUPPLY PIPING ASSUMED TO BE 3-DI, CONTRACTOR
SHALL POTHOLE AHEAD OF TIME TO DETERMINE
MATERIALS NECESSARY TO CONNECT TO EXISTING
SYSTEM.
210 210 SHUTDOWN WILL BE REQUIRED TO REMOVE THE
3 C11 DUSTING VALVE AND INSTALL PLUG ON THE DUSTING
TEE. COORDINATE SHUTDOWN IN ADVANCE WITH TVWD
IN ORDER TO NOTIFY CUSTOMERS. WORK WILL NEED
TO BE PERFORMED AT NIGHT OR DURING A WEEKEND.
ALL WORK ACROSS LINCOLN STREET MUST BE
z I COMPLETE BEFORE METZGER ELEMENTARY SCHOOL
BEGINS.
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REGON
20+00 21+00 22+00 23+00 24+00 24+40
8 PROFILE
SCALE, I'-20'HORZ 11,6
I"- 5'VERT EXPIRES: 06/30/2016
ONE INCHt' DATE: 05/2016
iCt LINCOLN CENTER WATER MAIN
ONE INCH AT FLU SCALE. PROJECT NO.
Tualatin Valley Water District 1365A
o IF NOT ME"A"ST SCALE
AOCORDINCLY
'all's REPLACEMENT PROJECT
ACCT. NO.
C12429
DRAWN;_ CCK DATE 05/16
DATE.- 05/16
DEsjcNED-. NEA ct i,qineerth- PLAN & PROFILE STA SHEET NO.
215 W 4th Street,Suite 200 `000111 9 OF 21
< REV DESCRIPTION BY DATE CHECKED' WWI DATE.- 05/16 Vancouver.WA 98660 1850 SW 170th Ave., Beaverton,OR 97003 (503)848-3000 i&,AA.N-wd.org 20+00 TO END DWG NO.
REVISIONS APPROVED: RCW I DATE. 05/16
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NOTES:
vailable Working Hours with Lane Restrictions: 7 AM to
4 Mon- Fri.
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II sign spacing as shown, or best suited for field conditions, per
,. MUTCD requirements.
Sidewalk Closure signs on Type II Barricades.
�FpF Open up all traffic lanes and sidewalk during non-working hours.
TOS OPCP elements and configuration flip when working on east side of
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Date: 7/29/2016 Author: SAR Project: Lincoln Center Water Main Replacement Project
Comments:
`1v_71VI
fyL C12429- Lincoln Center Water Main Replacement Project
(UTILITIES Lincoln Street Traffic Control Plan
Submittal#012.00 NOT TO SCALE