PFI2018-00291 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
= COMMUNITY DEVELOPMENT Permit#: PF12018-00291
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 10/25/2018
Parcel: SEG2733
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: PGE Job M2507665
Project Description: SEG2733, associated with 12130 SW Tiedeman Ave. Replace& Relocate pole and anchor. PGE Job
M2507665
Owner: FEES
Description Date Amount
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
TOD SHATTUCK
10800 SW AVERY ST
TUALATIN, OR
PHONE: 503-464-7777
Tota 1 $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: LeL
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12018-00291
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. Carla Staedter @ 503-718-2788
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
RECEIVED
OCT 24 2018
City of Tigard
CITY OF T►CARD
PUBLIC WORKS —ENGINEERING PLANNING'
EJGINEERING
Public Facility (PFI Permit
all
TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way)
TYPE 1—Franchise Utility Work-
Check
orkCheck one: QUtibfics ❑ Sidewalk/driveway approach ❑ Street improvements performed by NWN, PGF
Detailed description: Replace&relocate pole and anchor and/or utilitti�agency.
El TYPE 2—Sidewalk/Driveway/Sewer
PGE Job M2507665 Work performed for the purpose of:
• Sidewalk installation or repair.
11958 SW Tiedeman Ave • Driveway approach installation
Property address/location(s): and/or repair
Tigard, OR 97223 • Sanitary sewer lateral installation
and/or main line tap
Porland General Electric ❑ 'TYPE 3—I-'ull scale Development
Applicant: Work performed with Land use
Address: 10800 SW Avery St approval which includes any of
City/state: Tualatin, OR zip: the following:
Phone: 503-464-7777 Email: •preregcoord@pgn.com • Subdivisions or Partitions
Tod Shattuck 503-672-5466 • Street widening
Contact name: Phone:
• Mainline installation for Sanitary
Contractor: Porland General Electric sewer, Storm sewer, 'Tigard water
103663 and/or Tigard Water Service Area
CCB#: l?xpiration:
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
Applications for"minor work in right-of-way"
only may be emailed to:
Engineer: NSA rgMTermits&jjga�gov
Address: 131111111111111111111
City/state: Gip: F j,Zp( ddZ�
Phone: Email: Case No.: P9_"
j_
Contact name: Application submittal fee(007%of
Engineer's Estimate) $
Estimated value of work is required(if over$5,000):$5,100.14 Additional fees: $
(within the public right-of-way) Application accepted: 7
By: J C Date: ` (�
Is work related to a LAND-USE DLCISION? ❑ Yes NX No
If so,please specify (MLP,SDR, SUB, etc.) case #: Application reviewed: Q fit
By: �" Date:
Is work related to a BUILDING PERMIT? ❑ Yes No Applicant notified:
If so,Pleasespecify(B UILDIN(i PERMI case#: By: Date: 10
T)
I:\ENG\PermitApplications\pfi_application Rev.10/16/2017
City ofTigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 wwwtigard-or.gov 503-718-2421 • Page 1 of4
APPLICANTS
NOTE: Person specified as`Applicant"shall be designated"Permittee"and shall provide financial assurance for work,it
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 owners 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
ro e
• 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.
Vi n h D Nguyen Digitally signed by Vinh D
Nguyen,PE
PE Date:2018.10.17 16:11:18
07'00'
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
Owner's signature Print name Date
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2421 • Page 2 of`4
DEVELOPMENT ENGINEERING FEES FOR STAFF USE ONLY
Public Facility Improvement(PFI) Permit: DETAILED SUBMITTAL
REQUIREMENTS
APPLICATION FEE
Part 1: Required submittal fee$300.00 (minimum) FRANCHISE UTILITY AND SIDEWALK/
DRIVEWAY AND UTILITY
PERMIT FEE CONNECTIONS,ETC.
Part 2: All non-water system improvements (work in the right of way)
Engineer's estimate X 5%(less$300.00 minimum
submittal fee) Sketch
Engineer's estimate X 2%Plan Review (including information below)
❑ i)imensions
WATER SYSTEM FEE ❑ Street Name
Part 3: All public water system improvements ❑ Site Address
Engineer's estimate X 12%
FULL SCALE DEVELOPMENT
PFI Permit Fee Exemptions: (Subdivisions/Partitions and Street Improvements)
There will be no permit fee charged,or assurance required
for the following types of work: Design Plans
• Sidewalk repair(less than 20 lineal feet) (G sets,24x36 or 22x34)
• Relocate or replace mailbox ❑ Cover—Site,Vicinity,Abbreviation,Legend
• Ditch cleaning that does not involve regrading. ❑ General Notes(City,Water,Sewer,etc.)
• Weep hole repair ❑ Street(Plan,Profile)
• Curb repair or replacement(less than 20 lineal feet) ❑ Water,Storm and Sanitary(Plan Profile)
• Lawn sprinkler system installation or repair ❑ Water Quality Facilities
• Street tree pruning or planting ❑ Grading
• Planter strip landscape maintenance ❑ Landscaping/Tree Plan
• Test wells ❑ Composite Utility Plan(Electrical,Phone,Gas,
Storm,Sanitary,Water,Signage,Street Lights,etc)
❑ Details
Note: A cash/bond assurance may be ❑ Traffic Sight Distance
required per TMC 15.04.140. ❑ Signing and Striping
(customer deposit) ❑ Street Light Plan and Photometric
❑ Engineers seal/signature
❑ Sheet label(project land use name,revision and
plan log block,dates and sheet numbers.)
Additional Submittals
(per Land Use conditions)
❑ 'Traffic Report
❑ Storm water Drainage Calculations
❑ Geotechnical Report
❑ Preliminary Access Report(Sight Distance)
❑ Proposed Plat
❑ Pathway Design(if applicable)
❑ Water Department Approval
❑ Engineer's Construction Estimate
PUBLIC FACILITY IMPROVEMENT PERMIT
City ofTigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtlgard-or.gov • 50.3-718-2421 • Page 3 of4
SAMPLE SKETCH:
sw ?' Y St
Edge of Pavement
Ditch
Streetlight I .—.-------•—.—.—r—.—
• d Rsaf►nita1
i `'Mo""
� 4
' T�"rrroj)'os' cf'S��nreiTine'"'
,� Existing House
- I Existing
5-111 D rivewa y
01 UJI
.r-
01 01 I
(71
411
;
0i I I
. I Existing Shop
Rowerpole
_„ 6 • a
-------
. I � property Line ----------
I I
Fire Hydrant(FH)
I
I I I
Scale: 1"=30'
� I I
I I �
' I
I I
I � �
MINIMUM SKETCH REQUIREMENTS (Put "N/A"if Not Applicable):
North arrow Property lines & dimension Slope of property
Street &street names) Existing building, structures Utility&street light poles
Proposed work Existing curb or edge Trees
Existing S/W or of pavement Existing utility locations
D/W apron (sewer,water,storm)
PUBLIC FACILITY IMPROVEMENT PERMIT
City of-Tigard - 13125 SW Hall Blvd. - Tigard,Oregon 97223 - www.tigard-or.gov - 503-718-2421 - Page 4 of4
5'-4
OVERHEAD LEGEND
1997 ^�y.�V REMOVE,ABA NDONFAC _INSTALL FACILITIES
. VIP INSTALL ADDITIONAL FACILIDESIMODIFYFACILInES
1 WORK LOCA77ONS
POLES
40 T POLE CLASS(1,2,3,4,H1,H2,S)
a C!
5068
9` POLE HEIGHT
45' FRAMING TRANSMISSION&DISTRIBUTION(SEE CODES BELOW)
19 _FRAME DISTRIBUTION-LC10711,MU 0251
J25I (3PH 10FT HVY,ALLEY,TANG)
ANCHORS
x x _
J
Lu C
S = = Z
Q
AD) 0 a 0 � a
A_ (LE(LBS)
Anchor Code A7 A3 A5 A7 AS
GUYING
o �
G_ci
d o d a
�G OS.-LBS,' c�5
1 GUY G1 JG5G8
G101G1
O
�O2 2GUYS G2 G11 G13 GUYS G3 G1 G1 G21
PJ
_0101eP�
2 .1O.
�a • 45'-3
v' \None
P
0P
N
2175
45'-4
1952
WL 1 PL-2176: PGE OWNED POLE
Install:
POLE,45'-3
27'NE
(2)D251-DUAL ALLEY ARM
WILDLIFE-PHASE COVER
A3(SIDEWALK)-L=8'-43,185#
G23-PRI-17,004#
G19-NEUT-11,316#
Transfer:
STREET LIGHT
12060 R
POLE,45'-4
D50
A3
23
TEMP TRANSFER COMM(S),
PGE PULLED
TOPPED TO COMM(S)
TELCO TO PULL
0 35 70 140 Feet
11240 1 i '4 I I I I--'1 12270 10515 1050``.
PGE CONSTRUCTION DRAWING
AS-BUILT VERIFICATION&NESC VIOLA77GN5 CORRECTFO
T'<ec t,<.Fi n'
Foreman: Date.
THINKe®RS
Genera!Foreman: Date
(S)gnature onty required for Geld construction changes I
SDPM/ENG REVIEW ASBUILT BY DESIGNER:
DATE SCALE ACCOUNT AWO JOB NO
NYDEVL477ON FROM THIS DESIGN MUST10/17/2018 1 in=60 ft 1070001 1000004545 1 M2507665
BEAPPROVED BY THE PGE PROJECT MANAGER TITLE
REPLACE 45-4 WITH 45'-3
CALL 811 BEFORE YOU DIG CIRCUIT S1
ZE
ATTENTION: CALL 177
x 11
OREGON LAW REQUIRES YOU TO FOLLOW RULES ADOPTED , /pGE LOCATION
BY THE OREGON UTILITY NOTIFICATION CENTER- E 11958 SW TIEDEMAN AVE,TIGARD,97223
THOSE RULES ARE SET FORTH IN OAR 952-001-0010 1 ###"' DESCRIPTION
THROUGH 952-001-0090 YOU MAY OBTAIN COPIES OF RELOCATE POLE AND ANCHOR FOR CITY OF TIGARD SHEET
THE RULES BY CALLING THE OREGON UTILITY COUNTYSECTfONS WORK WITH
NOTIFICATION CENTER ADMINISTRATION @(502-232-1987) WASHINGTON C1134D 1 1 OF 1
TO REQUEST UTILITY LOCATES CALL THE OREGON OVY• BEAVERTON DESIGN BY PHONE DRAWN BY
UTILITY NOTIFICATION CENTER,811 AT LEAST Call before you di% LINE CREW CENTER Tod Shattuck 503.672.5466 SARA MCCAUGHAN
2 BUSINESS DAYS PRIOR TO EXCAVATION ss I3 SW I.RD DR ®PORTLAND GENERAL ELECTRIC CO-ALL RIGHTS RESERVED