PFI2018-00220 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
_ COMMUNITY DEVELOPMENT Permit#: PF12018-00220
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 08/27/2018
Parcel: 25111 CD10300
Jurisdiction: Tigard
Site address: 9830 SW KIMBERLY DR
Subdivision: KEVINGTON Lot: 4
Project: Comcast
Project Description: SEG 2321, associated with 9830 SW Kimberly Drive. Directional drill from the ped. on the north side of
SW Kimberly Dr.going south crossing the street. 70' in ROW 31'street placing 2"pipe at a depth of 36"
to provide CAN service for 9830 SW Kimberly Dr.Job#861991
Owner: FEES
Description Date Amount
PFI Permit Fee 08/24/2018 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
RANDY SHIELDS
11308 SW 68TH PARKWAY
TIGARD, OR 97223
PHONE: 360-301-1962
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:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12018-00220
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 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
AU G 2 12. 3
c City ®f Tigard
CITY OF T
PU13T-ff.] \V'0R1-',-S — LNGINErRING
PLANNING/El:._--.
,<<_
-nit
Public Fadhty Improvement
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TYPE Or WORK
DESCRIPT ON OF WORK (in the right-of-wiry)
❑ TYPE 1—franchise U JItt •\Turk
Chcck onc: Llriliucs ❑ Sidc\vitlk/drip c��a� approach ❑ tirrecrimprovenlcnts performed b\ N\\N, YG L:
a�;cncy.
Dc tailcd descriptio)n: Drectional drill from the Red on the nQtjh side of SW and/c,r urilit�
Kimberly DR.going south crossing street,70'in ROW 31'street placing 2"pipe ❑ TYPE 2—tiidcw« lk'l?rlvcwa,
\\;'orl:herlc,imcd f'ol ncc hurpc,sc cis:
:3t a depth nf_3f;"to nrmirlP rATV cera/ire fnr AR10 SW Korrshprly nr. q77??4 Sidewalk inst:tllaiion or rcpaii.
� 9830 SW Kimberly Dr, 97224 D,ivcwap approach insrall,,ti�,-1
I ,i:;opert)' address Y and/or repair
Job#861991 � �� Sanirar\-scwcr IaCcral ills[A11:16,011
and/or Illalil lisle.tap
Rand Shields for COMCAST CABLE ❑ TYPE 3—Full scale Dcvelopnlem
°\ppltcant: Y Work perfnrmcd\60i Land use
Address: 11308 SW 68th Pkwy app,c>vaI ,�711'ch includes;t1l).[:)17
state: Tigard, OR %il,: 97223 the following:
360-301-1962 Rand Shields cable.domcast.com Subdivisions or Partiriotls
Mone: Ltnai.l: Y_ @
C0ntact
Rand Shields 360-301-1962 • Strectwidening
name: Y ] hone:
• i\lainlitic installation for S;11111 s11-v
t.:
Fisk Communications Contracting Inc sewer, Storm sewer, '1"iprd watcr e:m rractol�: g
and/or'flpard\\%Ater 5crvicc Arca
C;CB#: ORCCB#185632 .Expiration: 02/24/2019
\ddress: 2705 NE 65th Ave S.1BIWITCOMPLETED APPLICATION TO:
( it\%srace: Vancouver, WA Zip: 98661 City of Tigard
Planning/Engineering
Phone: 360-314-4454 I_mail: fccambern@gmail.com
13127 SW Hall Blvd.
Contact name: Amber Nantz P110t1c. 360-314-4454 Tigard,OR 97223
Appiicmlons ft»•"minc,t W(111;in fight-c,t-.;c}"
oifly be c:tll:tilct.l tri:
I Algtticel rote en uts q)tigard-or.gov
-address:
City/sra.t.e:
Ph C: Email: Case No.: ��'lull —G,0 2210
Contact name: Applicadon subtllittal fee(Q71i0 of
Etigincer's Estimarc) S b®•��
L:sumated value of work is required(if over X5,000):S' Ad'dliional fees: 5
(within the public Applic"M011 irceprcd:
Tap
Is wc3rk tclated to a LAND-USI--` I7I. CTSI(�N? ❑ Yes []x No
_Application reviewed:
If so, please speci fy (1\41_P, SDR, SUB, etc.) case :
By: At.4414 Date.: ge-z -d's
Is work related to a BUILDING PE:.R1\II1? ❑ Yes O Na \pplica,lt tlt?tifted:
I su,please specify(BUILDING PE'TZ;\�IT7�case#: 13\x: C Uat:c:
I:\ENG\i�ermitApplicationz\pfi application Effective 30/16/2017
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Cite of Tigard 1312: S\V l-loll Blvd. "Tigard,Or,gon 9/223 wwNv 1prd-or.gc>v .50-718-2=121 Page 1 of 4
APPLICANTS
NOTE: Person specified as "Applicant"shall be dcsigmated "Permittee" and shall proyicle f nanclal assurance for work,if
required by the city pursuant to'I Iv1(_; 1 i.041.140.
\C ith the exception of;l utility operat.in;;pursuant 10A V;Ilid franchise with tic Cin•ofTi;;ard,when the owner and the applicant arc(I fferent
ht:.3ltic,the applicant mint bt:the purCI%tScr of I'Mird or a Icsscc in possession Faith wtittcn authonzatie,rt fium the wwncr or an a};ent of the
tMmrr. 'I'll(:o ncr(s) must sign this application in the space provldcd or:,uhmit a written authc�ri•r.:ttion with this application. Vranehised
1.tilitics arc not rcyuircd to obtain the OWttcr's s gIJ:Iturc on the application
BY SIGNING BELOW,THE APPLICANT(S) SIiALL CERTIFY THAT:
• The nbave request docs not vic�latc ally recorded deed restrictions 1:1111 nlay beattached to or imposed Upon the suhiect
beet lcrt�.
• 1f the application is s;rarlted, the applicant will exercise the rights(;ranted in accordance«'irh the cernls and subject to all the
conditions and hinitation,of the approval.
• All of the above statements incl the statements in any plot plan,attachments,and exhibits transmitted herewith,are true;and
the applicants so acknowledge that any permit issued,based can this application, may be revoked if it is found that 111\'Such
sinicillents 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 applicatioll.
\l�l�licant/ \utharized :;\gent's signattlre Print nan-le Date
SIGNATURES of each owner of the subject property, if required.
0wner's signature Print name Date
Owner's SignaturePrt17t I1VI71c Date
)'�\'11CL'�S C1 1];1CU1'C Print name Tate
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PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard 1312.5 S\N! (-Tall Blvd. • Tigarcf,Oregotl')7223 • x1,A-,,A -or.gov 703--18-2421 Page 2 of 4
DEVE,LOPMENT ENGINEERING FEES
Public Facility Improvement(PFI)Permit:
APPLICATION FEE1`:
Part 1: 11cyuircd submittal fee$300.00
FRANCHISE UTILITY AND SIDEWALK/
PERMIT FEE DRIVEWAY AND UTILITY
CONNECTIONS,ETC.
Part 2: :111 non-water system inzprnvesncizts (%%101-k in the right of wai!)
Engineer's estimate X.5�%0 (less S300,00 submittal fee)
1_:ngincer's estimate X 2c',4o Plan.Review Sketch
(including information below)
WATER SYSTEM FEE -
❑ Dini6asic5ns
Part 3: An public water system improvements ❑ Street:Name
1 nginc•.cr's estimate•.X '12°Fo ❑ Site Address .4
PFI Permit Fee Eaenzptions: FULL SCALE DEVELOPMENT _
"There will be no permit fee charged,o assurance rccluired
for the following t rpcs of work: (�LibC1iV1S1C?115artitic-ills acid Strcet lnzpron•crnc.nts')
• Sidewalk repair(less than 20 I.iizeal feet)
• Relocate or replace Inailbox Design Plans
(G sets,24x36 or 22x34)
• Ditch cleaning that.does not involve regrading.
• Wecp hale.repair ❑ Cover—Site,�'icinir�-,<lbbreviatian,Lcgend
• Curb repair or replacement (less than 20 linea} feet) ❑ General Notes.(Cit).-,\\-Iter,Sewer,c•(c.)
• La,,vn sprinkler si stem installation or repair D Street(Pian,Profile)
• Strcet tree pruning or plant:tizg ❑ VIatcr,;Storm and Sanitary(flan Profilc)
• Planter strip landscape 177a1ntenallcc ❑ \VZter.Qualirti-Facilities
• "T-cst wells ❑ Grading :.
El
1.ariYcisciping,/"1 rce 1?lan
❑ C:oliij-)cisite Utilitt Plan(E.lcctrical Phone,(aas,
Stu.rczz,Sanital ,water,Signagc,Strcct
A,oie: A cash assurance may be required per
T1l1C 7 5.04.140.(customer deposit El❑ 1'raf is
�dt-tic Sight Distance
❑ Signing and Striping
❑ Street Light Plan and Photonzetric
❑ Ivizl�ineei-s seal/signature
Sheet l:iliel(lu,ciject land use dame,revision:end
lnn lob bleiek;d itcs stod sheet nellnbers.)
Additional Submittals
(per Land 1 Ise conditions)
❑ 1'raffic Report
❑ SCornz wat.cr Drainage Calculations
❑ Ge0t,06111callZep0171'
❑ P:relist')ihary Access Reporr.(Sight:Distance)
El"Prop%ed Plat
❑ PathRra)""DCsjgn(if applicable)
❑ 1 jatcr T)cpar"tment:llpproval
❑ Enl';lileer's C.onstnictlon Estimare
^e ..£.���=;::c`��:as�tatt::. *:x:»..rsT��,:�•:����-a: �:s��r.'��.u"��.�..t� �E:c.t,��:.w.� .�:.^yxs:��:>t�+-.�vae°.. ".7r.4,._:. sx.:�>:.�<car!'c:.. .:eswtix:ss::�:s.,�,,;.....,xxst� .«...-_'°`+„�':.^qtr>'�t+,...attis�; ......u._.�si
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard 13125 S\\'f-Tail Blvd. - 'higard,Oregon } 223 5()'-718-242'1 Purge 3 of 4
SAMPLE SKETCH:
I Edge of Pavement
fl -
p - Ditch
Streetlight ®-�•�.�®••.®•®.�•�8��,®.�,.
pRain Drdn
a
B
lorrOp®s e it IIRe
a I24
0 a Existing House Q
�m I Existing
Z, B Driveway
01
a�
a- I ° •:vim �
e Existing Shop
Power,rpollee A
I !Cl- 95" r
I I •
e
e B
Fire Hydrant(FH)
!
II ! scale, 'I"=30'
•
I B I
•
' I I
I � •
I
MINIMUM SKETCH REQUIREMENTS(Put"N/A"if Not Applicable):
i o rtl} arrow Property lines& dimension Slope of property
Street &street name(s) Existing building,structures Utility&street light pales
Proposed work Existing curb or edge Trees
Existing S/W or of pavement Existing utility locations
I)/W apron (sewer,water,storm)
. ..:�.,::.::;�r-.:..xx.riz��rtz::tfw�•::ro:�r:.+x:;�u�:aur-t_r,:zs'aurarnsor,:rsza<satv�wvstw^cxx manesus !sl:r.,raetxaruw.�tie�+y'.�.w..t at^_v�re+nseoerr�.myna.—ar.,ae;rncs�ar.»x',^.a���+:t ��as�.:.xv_:azun.�xa�:rea-rz+•.�y.�..^.e'a�tm?f+tns.cu:
PUJBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SSV Mall Blvd. • Tigard,Orcgcm 97223 • x%vA%tigard-or.gov • 503-718-2421 • Page 4 of 4
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Fisk Communications
ContractingInce
(360) 314-4454
2011 Edlllon
01 page 77
• i
ZW,brk Vehlole
(Optlonal)
i
i
ROAD
* 0 or more oones '--�—_.�. WORK
mey be plaoed ` * ""'� AHEAD
behind vuhlole
for added vislbillty
V: hlole mounted
(Optional)
1.r 11e maximum
i
s
r
i 1
OAO
.... Y T O R K
i
1 A IEAD
1niII(il W arning Sign
(Optional i, See Mote 6)
a
8eplember 2096 Chapter 6
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