PFI2017-00264 City of Tigard e COMMUNITY DEVELOPMENT DEPARTME 0
Request for Permit Action
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits dgard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or Individual) Rt6c,, UNr` ;-e ,��� o tit(tSSa"
Mailing Address: PO ht-
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓):
CANCE OID PERMIT APPLICATION.
ND 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#: f PW-aag-6 i1
Site Address or Parcel #: �„��' I �- S'� L Sai k
Project Name:
Subdivision Name: Lot#:
EXPLANATION: ��,(St�k c� '1-0
Signature: G Date:
Print Name: 'St> c M
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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' ONIN
Route to Sys Admin: Date By Route to Records: Date 2 By 7634=
Refund Processed: Date - By Invoice Processed: Date B
Permit Canceled: Date /2 B Parcel Tag Added: Date B
I:\Building\Norms\RegPermitAction_09 314. oc
CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12017-00264
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 12/04/2017
" Parcel: 2S 103AD02800
Jurisdiction: Tigard
Site address:
Subdivision: PATHFINDER Lot: 18
Project: PGE
Project Description: Located near address 12855 SW 107th Ct, Tigard, OR 97223. SEG1157. Replace UG secondary; Install
new Jbox; Remove SS WLC 10. PGE Job M231185
Owner: FEES
Description Date Amount
PFI Permit Fee 11/30/2017 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
NATHAN GRAVELLE
10800 SW AVERY LANE
TUALATIN, OR 97062
PHONE: 503-718-6303
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: �� L C �[cc
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12017-00264
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. Call Ken fisher at 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 holders
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
NOV 27 2017
City of Tigard CITY OF TIGARD
C
PUBLIC WORKS —ENGINEERING PLANNING/ENGINEERING
Public Facility Improvement (PFI) Permit
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
TYPE 1—Franchise Utility Work-
Check
orkCheck one: 0 Utilities ❑Sidewalk/driveway approach ❑Streetimprovements performed by NWN, PGE
Detailed description:
REPLACE UG SECONDARY; INSTALL and/or utility agency.
NEW JBOX; REMOVE SS WLC 10 ❑ TYPE 2-Sidewalk/Driveway/Sewer
PGE Job M231185 Work performed for the purpose of:
• Sidewalk installation or repair.
Property address/l • Driveway approach installation
and/or 12855 SW 107TH CT, TIGARD, 97223 and/or repair
• Sanitary sewer lateral installation
and/or main line tap
Applicant: Portland General Electric[Submitted by Amy Sweany] ElTYPE 3—Full scale Development
Work performed with Land use
Address: 10800 SW Avery Street approval which includes any of
City/state: Tualatin, OR Zip: 97062 the following:
Phone: 503-718-6303 Email: preregcoord@pgn.com • Subdivisions or Partitions
Contact name: Nathan Gravelle Phone: 503-718-6303 • Streetwidening
• Mainline installation for Sanitary
Contractor: NIA sewer, Storm sewer,Tigard water
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: NIA only may be emailed to:
rowpermitsC&,ti�ard-or,gov
Address:
City/state: Zip: kEEMEEMEMSEWr
Phone: Email: Case No.: f F 12,0 II I� 40164
Contact name: Application submittal fee: $ m ~
Additional fees:$
Estimated value of work is required(if over$5,000):$ N/A Application accepted:
(within the public right-of-way) By: SC- Date:
Is work related to a LAND-USE DECISION? ❑ Yes CdNo Application reviewed:
By: •Iii Date: l�- 2.�'{-7If so,please specify (MLI,SDR,SUB,etc.) case#:
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes No By: C Date:
If so,please specify(BUILDING PERMIT)case#: [:\ENG\Perm[[Applications\pR_appl(cat[on Rev.12/16/2016
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 wwwtigard-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,if
required by the city pursuant to TMC 15.041.140.
* With the exception of a utility operating pursuant to a valid franchise with the City of Tigard,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. Franchised
Utilities are not required to obtain the owner's signature on the application
BY SIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT:
• The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject
property.
• 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 any plot plan,attachments,and exhibits transmitted hereNvith,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.
�T�Z� S -e �A Vjky-5 L-\ Z ��
Applicant/Authorized Agent's signature Print name Dale
SIGNATURES of each owner 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 of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 2 of 4
Page 84 2011 Edition
'Stationary Lane Closure with Flagging Diagram 320
Diagram 320 covers total closure of one lane of a two-lane,two-way
roadway. See the detail inset for the layout if using a single flagger to control
both directions of traffic on low volume roads (less than 400 ADT)with good
sight distance as discussed below.
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. Flaggers at each approach are required if any of the following
conditions exist:
a. Night Operations.
b. Work space is over 200 feet in length.
c. Sight distance is less than 750 feet from each approach
through the lane closure.
d. Traffic volumes are greater than 400 ADT.
4. The length between the Flagger Ahead signs shall not exceed one
mile. Use Diagram 340—Lane Closure with Pilot Car if exceeding one
mile.
5. Cones should be used to outline the work space when curves or other
roadway alignments prevent clear direction for the motorists to pass
the work space safely.
6. Cones along the work space are recommended when posted speeds
are 45 mph or greater,when working under heavy traffic or when travel
lanes are narrower than 11 feet.
7. Extended queue signing (see Diagram 5-4)should be used when
traffic queues extend beyond the initial advance warning sign.
8. When flagging near an intersection,the"Flagger Ahead"(CW23-2)
sign should be visible to traffic entering from any side road. Additional
advance warning and Flagger Ahead symbol signs may be placed on
the side road(s).
9. Sign set-up and flagger placement shown may be used for intermittent
full road closures of 20 minutes or less.
10. The"ONE LANE ROAD AHEAD"(W20-4)sign is optional and should
be considered on high volume or high speed roads, or when extended
queues are expected.
Chapter 5 September 2016
CA ------------------------
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WL 2 VT-367(NEW JBOX):
LEGEND
Install: REMOVE/ABANDON FACILITIES_INSTALL FACILITIES
854-JUNCTION BOX 1730 UNFUSED INSTALL ADDITIONAL FACILITIES/MODIFYFACILITIES
12840 - - - - - - - • SURVEY GRID BOUNDARY
CONDUCTORS
INSTALL 1-410 AL-TX UG SECONDARY
*PROVIDED&INSTALLED BY PGE
12855 1-3"CONDUIT
*PROVIDED&INSTALLED BY PGE APPROVED CONTRACTOR
2 ABANDON SECONDARY CABLE
'GROUND ABANDONED CABLE PER LC24010-3
VT-367 EQUIPMENT
I INSTALL NEW JBOX
12865 V.D. =2.81% C2 1-03A *854-JUNCTION BOX 1730 UNFUSED
FLCKR =3.4% I V
I =
I � J
I N. CNQ
P4I0PAt-7TX- `I o Q
3 12860
1 VT-70
/THINK
SAFETY
128,5 FIRST
0 10 20 40 Feet 12880
t I I I I I I I IV ANY DEVIATION FROM THIS DESIGN MUST
a L-2082 BE APPROVED BY THE PGE PROJECT MANAGER
} -t1 AGRAM Pam 15, f
roti` CALL 811 BEFORE YOU DIG
-PL-1 56 �O�� � ATTENTION:
OREGON LAW REQUIRES YOU TO FOLLOW RULES ADOPTED •
- PL-5181 53 g3 04 BY THE OREGON UTILITY NOTIFICATION CENTER.
r".= THOSE RULES ARE SET FORTH I N OAR 952-001-0010
�t A 50 27217PD-9190
THROUGH 952-001-0090 YOU MAY OBTAIN COPIES OF
A 50 542VT 6 01 = P \ VT 367 THE RULES BY CALLING THE OREGON UTILITY
PGE 1730 SPLICE BOX NOTIFICATION CENTER ADMINISTRATION @(501-232-1987)
L-2083 TO REQUEST UTILITY LOCATES CALL THE OREGON Knowwhat's below.
P 343/4 UTILITY NOTIFICATION CENTER,811 AT LEAST Call bdoreyou dig.
PL-2086 A 10 3071
PL-2085 3'-90 ELBOWS �- 2 BUSINESS DAYS PRIOR TO EXCAVATION
��. ' 35'RADIUS
A 7i 41482 y 3 ro 1 SCH4o PGE CONSTRUCTION DRAWING
C PL-2 FOR PERM SVC
TRANSFORMER • MARK CAP&INSTALL ELECTRIC
to 20'OF 500 PULL STRING AS-BUILT VERIFICATION&NESC VIOLATIONS CORRECTED
.{ 754
� This document accurately represents FIELD Construction
�� J'1.13P"S A 75 4 $0�-6602 �1 ' TRENCH
Ail% !' i" R POLYMER COVER Foreman: Date:
_ '~• v" �".., MARKED ELECTRIC'
General Foreman: Date:
CONDUIT
MARKER (Signature only required for field construction changes.)
ST LT
TOP VIEW SDPM/ENG REVIEW.' ASBUILT BY DESIGNER:
VT 69 _ OPTIONAL
t. B 50 2 VT-7572 'L DATE: SCALE: ACCOUNT: AWO: JOB NO.
FINAL GRADE 9/21/2017 1 in = 20 ft 1 1070001 1000004545 M2311865
_ • • •: _ _ �...,• �: TITLE
A 25 3802 VT-7435 REPLACE UG SECONDARY; INSTALL NEW JBOX; REMOVE SS WLC 10
P� 7 8 •:'�•• I CUT CONDUITS OFF I • �•. '�• CIRCUIT SIZE
$4" • •: •• 2„MAX. I •:••*V •. •• - X 17
TIGARD 13362 11
1 rxl s �• •• �• ROD BY PGE '•'"••• PGE LOCATION
a7sg -s60 , r
.>� •• 12855 SW 107TH CT, TIGARD, 97223
/` \.__ __._L_—�— • DESCRIPTION
_ _ •,', ` REPLACE 410 UG SEC; INSTALL JBOX; RETURN SS WLC 10
•' •• • 1-sB SHEET
i / � 1-58 •�• s
�� � /_ 'y—" A \ •' rr;w.►• F ••.•• '`•• •'• '••�.'.,, COUNTY SECTIONS WORK WITH
- ----- --� __: _ _ r' WASHINGTON C2103A 1 OF 1
40
0 75 150 300 Feet •48"TRENCH •
•• • ••• BEAVERroN DESIGN BY PHONE DRAWN BY
I I I I I �' '� D ST LT 3/4'MINUSBACKFILL DUCT TO SERVICE LINE CREW CENTER NATHAN GRAVELLE 503-951-3714 HEIDI BOOMER
N UNDER SPLICE BOX MARK CAP&INSTALL 2213 SW 153RD DR
__ " �GE OPTIONAL 2aoF5ooaPULLSTRING 0 PORTLAND GENERAL ELECTRIC CO.-ALL RIGHTS RESERVED77771