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PFI2018-00012 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT li s COMMUNITY DEVELOPMENT Permit#: PF12018-00012 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 01/25/2018 Parcel: SEG495 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: GeoPacific Engineering Project Description: SEG495, associated with address 11375 SW North Dakota St. 2 six inch diameters core holes in the west bound lane of North Dakota for pavement evaluation. Owner: FEES Description Date Amount PFI Permit Fee 01/25/2018 $300.00 PHONE: Contractor: PHONE: FAX: Applicant: MICHAEL BAKER 14835 SW 72ND AVE. PORTLAND, OR 97224 PHONE: 503-598-8445 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: See application Issued By: ---- Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12018-00012 Type: Condition Name: Status: Severity: PFI_Street Imp 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—Street Imp 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_Street Imp 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_Street Imp 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_Street Imp 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_Street Imp 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—Street Imp 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_Street Imp 08-TRAFFIC CONTROL ADVANCE WARNING Applied Notice Advance warning of traffic disruption shall be provided to the public by placement of an approved advance notification sign at each end of the construction area 72 hours(min.)before initiation of construction work. PFI—Street Imp 11 -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—Street Imp 12-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—Street Imp 13- DRAINAGE CONTROL Applied Notice Drainage shall be controlled within the work site and shall not adversely affect adjacent private property, public property and the receiving system. The City may at any time order corrective action and suspension of work to accomplish effective drainage control. PFI_Street Imp 14-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—Street Imp 15-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—Street Imp 16-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—Street Imp 17-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—Street Imp 18-SEWER SYSTEM TEST Applied Notice A sewer system air-test and/or DVD T.V. test report and one set of"As-Builts"shall be provided for review and approval. PFI—Street Imp 19-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—Street Imp 20-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 Jonny Gish 971-713-0281 or email Jonny@tigard-or-gov PFI—Street Imp 21 -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—Street Imp 22-DAILY INSPECTION REPORTS Applied Notice Applicant shall submit daily inspection reports, on a weekly basis,to the City's Inspector. PFI—Street Imp 23-MONUMENT PROTECTION Applied Notice Existing monuments, property corners, and survey markers shall be protected. Replacement shall be at the permit holder's expense. PFI—Street Imp 24-VALIDATION OF MATERIAL/CONSTRUCTION Applied Notice The City's Inspector may, at his discretion, require tests and or reports from the applicant to validate claims of material or construction adequacy/compliance. Such tests/reports shall be provided at the applicant's expense. PFI—Street Imp 25-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—Street Imp 26-RIGHT OF ENTRY/EASEMENTS Applied Notice Applicant to obtain proper right-of-entry and/or easements prior to starting work. Proof of right-of-entry or properly executed easements, shall be provided to the City. The City shall in no way be construed to be liable for the applicant's failure to obtain or provide for proof of right-of-entry or easements. PFI—Street Imp 27-PRIVATE PROPERTY AGREEMENTS Applied Notice Provide the City a copy of an executed agreement[s]from the owner for each private property disturbed by construction activity- PFI—Street Imp 28-AS-BUILT DRAWING Applied Notice One as-built drawing showing all new public improvements, including any revision made to the previously approved construction plans and, also, any improvement which may impact an existing public system or facility, shall be provided to the City by a registered civil engineer along with an engineer's certification of installation compliance(Certificate of Compliance). PFI—Street Imp 29-PRIVATE WATER QUALITY FACILITY Applied Notice The Developer shall maintain the water quality facility and correct any defective work, and shall perform all scheduled maintenance to assure proper functioning of the facility. PFI—Street Imp 30-PUBLIC WATER QUALITY FACILITY Applied Notice The Developer shall create and provide to the City a schedule for periodic(quarterly) maintenance of the water quality facility. The Developer shall maintain said facility for a period of three(3)years from the date of City Conditional Acceptance of the public improvements. On October 1 st of each year during this three(3)years period, the Developer shall report, in writing, maintenance activities to the Director of Public Works. City crews should monitor proper removal and disposal of silt and debris. Prior to City final acceptance of the facility, the Developer shall provide a written evaluation of the operation and maintenance needs of the facility and correct any deficiencies identified in the evaluation. PFI—Street Imp 31 -OTHER Applied Notice RECEIVED City of Tigard JAN 2 3 2018 PUBLIC WORDS —ENGINEERING CITY OF 11GARD ANNINGIF_NGINEERING Public Facility Improvement (PFI} Permit TYPE OF WORK DESCRIPTION OF WORK(in the right-of-way) ��//'' El TYPE 1—Franchise Utiiit��Work Check one: El Utilities Elhd Sidewalk/driveway approach 'Streetimprovements performed by NWN, PGL Detailed description: � Sf,k l��rt��7��t+'3 UDrt Gidej and/or utility agency. •7 f'�C ✓Ld- , , TYPE 2—Sidewalk/Driveway/Sewer Work performed for die purpose of Yw��"�`" n - Sidewalk installation or repair. Property address/location(s): 1 1 3 S LJ V J r h • Driveway approach installation and/ter repair S c.r-;4 • Sanitary sewer lateral installation KEG415 and/or main line tap I 1 n f � /� El TWE 3—Full scale Development Applicant: u,G t i�a r [.r1C�>I'aie:. �; aye •�tft..� Work performed with Land use Address: S 5(y 7,1,pei '-e ' approval which includes any of City/state: 2 P3 e��� �� Zip: 7 the tollouving: Phone:970 3 Il qY%q'-Email: M lC+L�.er k jea Onc.& e•� ,W,-% - Subdivisions or Partitions - Street widening Contact name: Phone: �, 1 a �(090 • Mainline installation for Sanitan Contractor: 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" only may be emailed to: Engineer: rowtx rtni tsfu�t ip.ara-or.tov Address: City/state: Zip: 11 0012CPhone: Email: Case No.: rfuoig` 00012- Contact ontact naive: Application submittal foe(.071/9 of Engineers Estimate) S��• Estimated value of work is required(if over$5,000):$ Additional fees:3 (within the public right-of-way) Application accepted: Is work related to a LAND-USE DECISION? ❑ Yes ❑ No 13y: ic u:tte: Application re 'cwcd: If so,please specif, WLP,SDR,SUB,etc.) case#: By: 1 Date- Is work related to a BUILDING PERMIT? ❑ Yes ❑ No Applicant n t,lea. If so,please specify(BUILDING PER2\111)case#: By: � Date: JA-2 1:\ENG\PermltApo ketWo\pfUpplkatfon EHCth a 10/16,/2017 City of Tigard • 13125 SW Na11 Blvd. • Tigard,Oregon 97223 • umvw:tigard-ongov 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 T?\1C 15.041.140. * With the exception of a utility operating pursuant to a valid franchise with the Cite 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 oa-ner or an;gent of the owner. The owner(s) must sign this application in the space provided or submit a written authorization�vith this application. Franchised utilities are not rcyuircd to obtain the owner's signature on the application BY SIGNING BELOW,THE APPLICANTS) SHALL CERTIFY THAT: • The above request does not violate any recorded deed restricdons that may be nttaehcd to or ianpo%sed anon 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 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. t4 ex Applicant/Authorized Agent's signature Print name Date SIGNATURES of each owner of the subject property,if required. Owner's signature Print name Date Owner's signature Print name Date 0xvner's signature Print name Date PUBLIC FACILITY IMPROVEMENT PERMIT Cityof Tigard 13125 SSW'Hall Blvd. • Tigard,Oregon 97223 • wwwaigard-or.gov 503-718-2421 • Page 2 of 4 >�_ 14835 SW 72nd Avenue SITE AERIAL AND Geopme Portland, Oregon 97224 Tel: (503)598-8445 Fax: (503)941-9281 ROAD CORE LOCATIONS rL f4WICOTTONWOOD Lk. 46 V I t � � I I Ilta..'1 i' _,,.,.. .- .-- _: sir e I ` YYiM1F I'm}� rts+rJ s ✓ ~r I i ns r .—7 1isaSF I r W.1TRF , _....... _ t 1 I c, rERFACIL 4. 3 ura 649"(T*). ti miff 5 Inr ba v t Isr g SW FOREST LN / t� I � t to R41 W North Dakota Street,,_.,, - - - --- North w , Legend Date: 1.22.2013 R -1 0 120' Drawn by: MTB Road Core Designation Site Boundary ' and Approximate Location APPROXIMATE SCALE 1"=120' Project: North Dakota Subdivision Project No. 18-4824 FIGURE 1 Washington County, Oregon m tD Single Fiagger Operation j O 4n 4 N O In O V+ D to 3 � CD CLL I for Low Volumes .� —• m (Opvow p a Q m T<qpp ro . Et I ) BE pu rnCU FLAGM �. M`; i I PREPARED 0���E S ao -- x! 2► I TO STOP AHEAD —► •. ® •� ,� ( ROAD 8 8 8 " ~ ' K�K'K.''.. - ---4 — WORK s I I AHEAD wory,M wne► ., n� c rj � ,� � • wi nM DoH OAa.1 o 0 0�0 a g Ln to ; :»ard.• I C TO 110 I "q-z I ,Y 1 I •1•r----s..� 0-0 1 mile max. w F--C -;-• B B J Buffer � PfOtBCtipn Vehicle ROAD w/TMA(both Optional) WORK See Chapter 4 AHEAD BE ONE LANE PREPARED AHEAD TO STOP Two Flagger Operation in (Opal) N rn o Ln ACS® CERTIFICATE F DATE(MM/DD/YYYY) C C O LIABILITY INSURANCE 9/28/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTANAME:CT Sandra Ramirez Davidson&Associates Insurance Agency, Inc. PHONE . 360-514-9550 FAX 610 Esther St Ste 101 E-MAIL Vancouver WA 98660 ADDRESS,sandra@davidsoninsurance.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Ohio Security Insurance Co 24082 INSURED INSURER B:Ohio Casualty Insurance Co 24074 GeoPacific Engineering Inc INSURER c:Trumbull Insurance Company 19666 14835 SW 72nd Ave INSURER D:Starr Surplus Lines Ins Co Portland OR 97224 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 332568576 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD/YYYY MMlDD1YYYY A X COMMERCIAL GENERAL LIABILITY Y BKS55301849 10/20/2017 10/20/2018 EACH OCCURRENCE $1,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $1,000,000 MED EXP(Any one person) $15,000 PERSONAL BADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY PRO- LOC PRODUCTS-COMP/OP AGG $2,000,000 JECT OTHER: $ A AUTOMOBILE LIABILITY Y BKS55301849 10/20/2017 10/20/2018 COMBINED SINGLE LIMIT $ Ea accident 1,000,000 ANY AUTO BODILY INJURY(Per person) $ AUTOWNED SCHEDULED OSBODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident B X UMBRELLA LIAR X OCCUR US055301849 10/20/2017 10/20/2018 EACH OCCURRENCE $2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED X RETENTION$10,000 $ C WORKERS COMPENSATION 52WECGB5894 11/1/2017 11/1/2018X PER OTH- AND EMPLOYERS'LIABILITY YSTATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 D Professional Liab N N SLSLPR026251817 10/1/2017 10/1/2018 Per Claim 1,000,000 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Additional insured wording does not apply to Professional Liability or Workers Comp. Certificate holder is named as additional insured with respect to operations of the named insured as per written contract.Additional insured wording does not apply to Professional Liability. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Tigard THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 13125 SW Hall Blvd ACCORDANCE WITH THE POLICY PROVISIONS. Tigard OR 97223 USA AUTHORIZED EPRESENTATIVE rL ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD