PFI2018-00061 VOIDED
PF12018 00061
PGE
F 4
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
= ~
Request for Permit Action
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • \Vw\v.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 )9\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/VOID PERMIT APPLICATION.
REFUND 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#: OGNO
Site Address or Parcel #:
Project Name: r-ID
Subdivision Name: Lot#:
EXPLANATION: VW r WA1M Perm k ticd U Y1dC.tr pR2 161'
Signature: Date: -71 L3 11(3
Print Name: h-Ps L.r�UY
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of-
Any
fAny 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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
WE 601
Route to Sys.admin: Date By Route to Records: Date B
Refund Processed: Date By Invoice Processed: Date B
Permit Canceled: Date B Parcel Tag Added: Date B
I:\Building\Forms\RegPermitAction_092314.doc
Agnes Lindor
From: Prereq Coord <PreregCoord@pgn.com>
Sent: Friday, July 20, 2018 7:47 AM
To: ROW Permits;Jonny Gish
Cc: Tod Shattuck;Josie Freeman; Prereq Coord
Subject: URGENT City of Tigard Permit Application, 9675 SW MCKENZIE PL, PGE Job M2534565
Attachments: M2534565 Sketch.pdf; M2534565 TCP.PDF; M2534565 City of Tigard Permit Application
SIGNED.PDF
Importance: High
Categories: Routed for Eng. Review
Good morning.
Attached is the City of Tigard Permit Application, Sketch, and TCP for PGE Job M2534565.
Please note that we request cancelation of City of Tigard Permit PF12018-00061/PGE Job M2128311. This Permit
Application for PGE Job M2534565 is being submitted to replace Permit PF12018-00061.
Thank you for expediting this permit application as the contractor is ready to start construction as early as next week.
Please contact Tod Shattuck at 503-672-5466 with any questions.
Thank you for all that you do.
Amy Sweany
E Administrative Assistant PSLD • 503-612-2935 • 503-612-6150f
� )
` 10800 SW Avery Street Tualatin, OR 97062
PortlandGeneral.com• Follow us on social @PortlandGeneral
1
CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
• COMMUNITY DEVELOPMENT Permit#: PF12018-00061
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 03/14/2018
Parcel: SEG1129
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: PGE
Project Description: SEG1129, associated with address 9785 SW McKenzie Blvd. Install third phase across Pacific Highway
and reframe new pole with 277/480 service to 600amp. PGE Job M2128311.
Owner: FEES
Description Date Amount
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
TOM SHATTUCK
10800 SW AVERY ST
TUALATIN, OR 97062
PHONE: 503-612-2935
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:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12018-00061
Type: Condition Name: Status: Severity:
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.
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
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.
RECEIVED
City of Tigard MAR 12 2018
PUBLIC WORDS—ENGINEERING GIS OF� �
R
ING!ENOINEERING
Public Fadity Improvement (PFI) Permtt
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of--way)
�/ 7
� TYPE 1—Franchise Utility Work
Check one: [)(Utilities ❑ Sidewalk-/driveway approach ❑Streetiinprovements performed by NWN, PGE
Detailed description: Install 3rd phase across Pacific HWY and and/or utility agency.
install new pole with 2771480 service to 600amp. ❑ 'TYPE 2–Sidewalk/Driveway/sewer
PGE Job M2128311 Work performed for the purpose of:
• Sidewalk installation or repair.
• Driveway approach installation
9675 SW McKenzie Street
Property address/location(s): and/or repair
Tigard, OR 97223 aanitary sewer lateral installation
and/or main line trap
Applicant: Portland General Electric[Submitted by Amy Sweany] [I TYPE 3–Full scale Development
pp Work performed with Land use
1J�• Address: 10800 SW Avery Street approval which includes any of
City/state: Tualatin, OR Zip. 97062 the following:
Phone: 503-612-2935 Email: preregcoord@pgn.eom • Subdivisions or Partitions
Contact naive: SDPM Tod Shattuck Phone: 503-672-5466 • Street widening
• Afainline installation for Sanitary
Contractor:
Portland General Electric sewer, Storm sewer, Tigard water
and/or Tigard Water Service Area
CCB#: 103663 Expiration:
Address: SUBMIT COMPLETED APPLICATION TO:
City/state: Zip: City of Tigard
Planning/Engineering
Phone: Email: 13125 SW Hall Blvd.
Contact name: Phone: Tigard,OR 97223
1\pplications for"minor work in tight-of-way"
only may be emailed to:
Engineer: NSA rovPermits@tigard or.gov
Address: FOR STAFF USE ONLY
City/state: Zip:
Phone: Email: Case No.: f f j z4j,w ()o06 I
Contact name: Application submittal fee(.007%of
Engineer's Estimate) $
Estimated value of work is required(if over$5,000):$ 20,456.34 Additional fees:$
(within the public right-of-way) Application accepted: II
�
Is work related to a LAND-USE DECISION? ❑ Yes � No By: Date:
If so,please specify (MLP,SDR,SUB, etc.) case #: Application-reviewed:
By: WZ, V.-Date:
Is work related to a BUILDING PERMIT? ❑ Yes [�(No Applicant notified: /9
If so,please specify(BUILDING PERMI 1)case#: By: J%. -Date: /1�4J
I:\ENG\PermltApplications\pfi_application Rev.10/16/2017
K.�,.e�J :a�E .er..a-m..'Pc�'.• '�7_�ls�<Sdt✓ r�.;�"'":�&'..�a.. ___ y�..�.ss� -
City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 «7xvtutigard-or.gov 503-718-2421 • Page 1 of
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'1'igard,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 frons the owner or an agent of the
owner. The owner(-,)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 APPLICANTS) SHALL CERTIFY THAT:
• The above request does not violate any recorded deed restrictions that may attached to or imposed upon the subject
12ro12
• 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,attaclunents,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.
_�. `z 5-�-�•.e �v � S�. 3 z��
Applicant/Authorized Agent's signature Print name D to
SIGNATURES of each owner of the subject property, if required.
Owner's signature Print naive Date
Owner's signature Print naive Date
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www tigard-or.gov 503-718-2421 Page 2 of4
WR CHECKLIST COMMERCIAL LEGEND
THINK ITEM YES COMMENT
00041 BOMICGER x NEW PGE FACILITIES TO BE INSTALLED
1962-60 SAFETY BACKHOE (UNLESS OTHERWISE SPECIFIED)
O FIRS 1 l PGE TRENCH
O FACILITIES IN GREEN ARE TO BE REMOVED
00023 LOCATES x INSTALL 1-#2 ACSR PRIMARY B PHASE
1966-35 STAKING x
FLAGGING x
-y' ---------- ADD /EXTEND 02 ABCN-2 ACSR TO THE NEW POLE 1
TREETRIM
LANDSCAPE ---------- INSTALL i-#350 AL-OX IN 2 OF 3-3"PVC CONDUIT
�er^� EASEMENT PROVIDED & INSTALLED BY CUSTOMER
ADO PERMITS IT ODOT- TIGARD INSTALL CUTOUT
01818- _ 260' 1-142 C/O REFRAME POLE fj� TWFIC PUN x v SIZE FUSING AS NOTED
2 65T ��, FUSE ALL 3849 WITH D-39 CUTSHEET
-}'� 00196/ o F65T B-2 AL-0,B UG CIR.VER.
O PLoo072 PP PL00041 q �. PL41 / S
00072 ��O Q ( `�
TRANSMISSIONT
1990-75 h P CUSTOMER
ff c�
01819- sx GF TO ADVISE
V' RIGHT-OF-WAY PERMIT NOTICE:
O Pte, q� 07256/ DOOR HANGER A PERMIT FROM THE LOCAL JURISDICTION IS REQUIRED BEFORE ANY
sw ` PL 03849 2-35 X CONTACT WORK IN THE RIGHT-0F-WAY ANY BE PERFORMED. ONLY PGE APPROV'TD
I�R CONTRACTORS AND CONTRACTORS WHO HAVE MADE OTHER SPECIAL
-� COMPANY AGREEMENTS WITH PGE WILL BE ALLOWED TO WORK UNDER PGE'S PERMIT,
THE
CO TRACTOR MV57 NOTIFY THE LOCAL JURISDICTION 48 HOURS
` PHI _ BEFORE WORK 15 TO BEGIN.A COPY OF THE PERM"MUST BE ON SITE,
DATE ?TME POLES
1965-45 1-142 EZ
OLE CLASS (1,2,3,4,H1,H2,S)
O L03849 OLE HEIGHT(FEET)
QA 16 416 PL 12
�� F6T42 C 25 79650 45-3 3-142 FRAMING TRANSMISSION & DISTRIBUTION (SEE CODES BELOW)
L0007220'L F40T
yll ♦ L 12 039 FRAME DISTRIBUTION-LC10720,WMS MU 0039
\ ♦♦ \ ��(3PH TANG.LT,SGL 8'Li,HVY BRACE,PIN)
PEN A 100 5616 2771480V
C 25 53962 600AMP 100' ♦ 081 FRAME DISTRIBUTION -LC10728,WMS MU 0081
11,105A AFC r; ♦ q U-D
(3PH SGL.DE,DBL 8'LT,POLY)
,A oaso6 O 3-142 coo < A_2 C
1971-3 F40T F40T F40T (A
f ALL 7200V i J� 4/0 GUYING x = x = u
T 2k Z a o a o
50 A6( 50 B0' 50 C6( PEAK LOAD B 50 (� Q ANCHORS = _ W Q I Pos.-Les z s
(r7� 124.$8KWC 5j�' "V' w > 1 GUY GI G°G7 1 G1d G19 11
2 GUYS JG2 GS G8 Gil 1 2t231
l� C ANCHOR CODE Al A3 AS A7 A8 3 GWS G3 G6 G9 Gl GI G2 21
012 PGE CONSTRUCTION DRAWING
fF` AS—BUILT VERIFICATION & NESC VIOLATIONS CORRECTED
\ This document accurately represents FIELD Constructlor
Foreman: Dote:
VICINITY MAP -12
D General Foreman: Date:
INSTALL 45'CLASSS 3 POLE SET @ STAKED LOCATION (Signature only required for field construction changes.)
RROCRAMII y, �V °� TAFLM F7RRY Rp ' FRAME 81
s SDPMJENG REVIEW: 1ASBUILT BY DESIGNER:
�k ~5 20'LEAD 45_3 DATE: 12,09/2016 SCALE: 1-:60' ACCOUNT: 1070001 AWa 1000004599 JOB NO.M2128311
AS TITLE
NOR H
17
E °AR0. ELrG19 7/16 D.G @ 12,118 STORE QUEST
kF
CIRCUIT SIZE
F F - nWRD "° F G16 M (Li) 4,702 TIGARD -TIGARD 1311V
WAL m 081 /GE LOCATION
t'eP
INSTALL 3"POLE CONDUIT UNIT O 12740 SW PACIFIC HWY,TIGARD
E WITH WEATHERHEAD ON 12'BRACKET DESCRIPTION
DONND
RONIIA RRUSr NEW 600AMP 2771480V
1gard Y 3"CONDUITS `/ COUNTY ECTION(5) WORK WITH SHEET
BEAVERN WASH C21-026
,G TOI OF i
BEEF.SHO R0 n"O11H1N1 RO LINE CREW CENTER DESIGN BY PHONE(503) DRAWN BY
2213 SW 153RD DR TOD SHATTUCK 672-5466 MARIUS LACATUSU
BEAVERTON,OR 97006
O PORTLAND GENERAL ELECTRIC CO.-ALL RIGHTS RESERVED
M U)- --------------- (n No
CL a Single Flagger Operation ,,,
for Low Volumes (Optional) o� a
N cn w N (ADT<4W) m iow
0) <*
O
0 0 o D MFL400MPREPARED ONE LANE
cc
3 = I I ?►c z• I TO STOP ROAD r
w CL AHEAD
Ln cn o 00
0 0 0 ; ♦ �. . .r. I • ROAD
® I WORK
o c`"i o n 3 3 I 't c K e K e K I---J I AHEAD
o O o f° I °�' I 0
Nmon
(n CoLn m
O O O O Ul O .10
�' low
i------------------------iT A
1 mile _I 'n
max. E
—• • • �• • • — — — — t4
to
B A
Buffer
Protection Vehicle
ROAD • w/TMA(both Optional)
WORK See Chapter 4 _0
AHEAD
BE
ONE LANE PREPARE
AH
EGAD TO STOP Two Flagger Operation
w CD
CD
(Optional) p C00
n