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PFI2019-00164 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT ° s . COMMUNITY DEVELOPMENT Permit#: PF12019-00164 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 05/29/2019 Parcel: SEG2468 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: CenturyLink National Project Description: REPRINTED 12/18/2019. Updated Applicant/Contractor Info.Adjacent to 16037 SW Upper Boones Ferry Rd. Bore and place 165'of 1-2"conduit along and across SW Upper Boones Ferry Rd near SW 72nd Ave. Class of Work: FEES Type 1 -Utilities(gas, electric,data) Description Date Amount PFI Permit Fee 05/29/2019 $300.00 Total $300.00 Owner: REQUIRED INSPECTIONS Call 503-639-4175 for the IVR inspection request line or visit the City of PHONE: Tigard website at www.tiqard-or.qov to schedule inspections online. Contractor: NORTH SKY COMMUNICATIONS LLC 11818 SE MILL PLAIN BLVD SUITE 410 VANCOUVER, OR 98684 PHONE: 360-254-6920 Applicant: TODD HURD 214 E 24TH STREET VANCOUVER, WA 98663 PHONE: 5034676422 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: �eC pp C413 Issued By: 4701V dew/L Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PFI2019-00164 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 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_Utilities 09-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 10-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 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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. PFI_Utilities 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_Utilities 22-DAILY INSPECTION REPORTS Applied Notice Applicant shall submit daily inspection reports, on a weekly basis,to the City's Inspector. PFI_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 28-AS-BUILT DRAWING Applied Notice 1,2,3,4,5 28-AS-BUILT DRAWING 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). 1,2,3,4,5 28-AS-BUILT DRAWING 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). 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_Utilities 31 -OTHER Applied Notice Other Agnes Lindor RECEIVED From: Christina Zellmer DEC 1 7 2019 Sent: Tuesday, December 17, 2019 1:53 PM pLANN GOF TiGARD To: ROW Permits IENGINEERING Subject: FW: 16037 SW Upper Boones Ferry Rd PF02019-00164 Attachments: N.504593-city of Tigard permit.pdf; City of Tigard Signed Application.pdf Is this the right place to forward this? Thanks, Christy From: Matt Oliver<Matt_Oliver@kbmail.net> Sent:Tuesday, December 17, 2019 1:49 PM To:Christina Zellmer<christinaz@tigard-or.gov> Cc: Hurd, Todd <todd.hurd@centurylink.com>; Glen Williams<Glen_Williams@kbmail.net>; Diego Barrera <Diego_Barrera@kbmail.net>; bstavang@northskycomm.com Subject: 16037 SW Upper Boones Ferry Rd PF02019-00164 Caution! This message was sent from outside your organization. Allow sender I Block sender City of Tigard, Attached is a permit that was previously approved on 5/29/2019. We need to change the applicant to CenturyLink National as well as the contractor to Northsky Communications. How should we proceed?Can you renew this and attach the attached updated application?There have been some internal changes at CenturyLink,that is the reason for this request. Please call or email me with any questions or concerns. Matt Oliver Project Manager 6566 SE Lake Rd,Suite F, Milwaukie,OR 97222 (503)650-6041 X222 Office (925)984-3385 Mobile Matt Oliverkbmail.net 1110TECHNICAL SOLUTIONS DISCLAIMER: E-mails sent or received by City of Tigard employees are subject to public record laws. If requested, e-mail may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law. E-mails are retained by the City of Tigard in compliance with the Oregon Administrative Rules "City General Records Retention Schedule." 1 2vision+0 ?H2.019-aDi404 RECEIVED n City of Tigard DEC 17 2019 PFI#: 111111 C ENGINEERING DEPARTMENT CITY OF T'GARD )' A\ININE!ENG.II EERING TIGARD Public Facilities Improvement (PFI) Permit to PROJECT INFORMATION 16037 SW Upper Boones FerryRd TYPE OF WORK Project name: pp ❑ TYPE 1-Franchise Utility Work Brief description of project: Bore and place 165' of 1-2" conduit performed by NWN,PGE, or utility agency along and across SW Upper Boones Ferry Rd near ❑ TYPE 2-ROW Sidewalk/Driveway/Sewer SW 72nd Ave. Work performed for the purpose of: • Sidewalk installation or repair • Driveway approach installation and repair SITE INFORMATION • Sanitary sewer lateral installation and 16037 SW Upper Boones Ferry Rd main line tap Location (address if available): ❑ TYPE 3—Full Scale Development Work Tigard, OR 97224 performed with land use approval which includes any of the following: • Subdivisions or Partitions APPLICANT INFORMATION • Street widening CenturyLink National • Mainline installation for sanitary sewer, Name: storm sewer, Tigard water, and Tigard Mailing address: 214 E 24th St water service area city/state: Vancouver, WAZip: 98663 ❑ TYPE 4-Small Cell Technology Phone: 503-467-6422 ❑ TYPE 5-Tigard Triangle Email: Todd.Hurd@CenturyLink.com Phone: 503-467-6422 NOTE: Type 1 and 2 applications may be Contact name: Todd Hurd emailed to rowpermitsitigard-or.gov. Phone: 503-467-6422 Email: Todd.Hurd@CenturyLink.com CONTRACTOR INFORMATION ❑ Same as applicant Name: North Sky Communications, Inc CCB Number: 208747 Mailing address: 10860 SW Clutter Rd City/State: Sherwood, ORZip: 97140 Phone: (503) 949-8195 (Brandon Stavang) Email: bstavang@northskycomm.com ENGINEER INFORMATION Name: K&B Technical Solutions Mailing address: 6566 SE Lake Rd (STE F) City/State: Milwaukie, ORZip: 97222 Phone: 925-984-3385 Ems: Matt_Oliver@kbmail.net ADDITIONAL INFORMATION Estimated value of work is required(if over$5,000):$ —$9599 (within the public right-of-way) Is work related to a LAND USE DECISION? ❑Yes El No Case number: 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 15.04.140. * With the exception of a utility operating pursuant to a valid franchise or license 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 must sign this application in the space provided or submit a written authorization with this application. Franchised or Licensed Utilities are not required to obtain the owner's signature on the application. I, the applicant, certify that: • To the best of my knowledge,all the information provided within this application package is complete and accurate. • 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,I will exercise the rights granted in accordance with the terms and subject to all the conditions and limitations of the approval. Matt Oliver Digitally signed by Matt Oliver Date:2019.12.1713:48:21-08'00' Matt Oliver(signed for Todd Hurd) 12/17/2019 Applicant's or authorized agent's signature Print name Date Property owner's signature (if required) Print name Date STAFF LSE ONLY Case No: Permit fee: Received by: Date: Approved by: Date: Notified by: Date: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 2 of 4 DEVELOPMENT ENGINEERING FEES Public Facility Improvement(PFI) Permit: INITIAL PFI PERMIT FEE Part 1: Required submittal fee is 10%of the Net PFI Permit Fee.See below for calculations.Minimum of$300. NET PFI PERMIT FEE Part 2: All non-water system improvements engineer's estimate X 7%(less the initial PFI Permit Fee). WATER LINE CONSTRUCTION FEE Part 3: All public water system improvements engineer's estimate X 12%. FOR STAFF USE ONLY FOR STAFF USE ONLY TYPE 4: SMALL WIRELESS FACILITY TYPE 1—3:DETAILED SUBMITTAL CHECKLIST REQUIREMENTS Does applicant have a right-of-way license? ❑Yes ❑No TYPE 1 AND TYPE 2-Must include a sketch showing: Under the wireless facilities standards,is the proposal ❑ Dimensions considered?(check all that apply): 0 Small Cell 0 Macro ❑ Street Name How many install sites are proposed as part of this permit ❑ Site Address application? TYPE 3-Must provide 4 sets of plans (sized 24 x 36 or 22 x 34) and an electronic version of all submittal The proposed equipment is located on which of the following: items. The plans must that include: ❑Public Right-of-Way 0 Private Property ❑ Cover—Site,Vicinity,Abbreviation,Legend If equipment is to be located on private property,describe the ❑ General Notes(City,Water,Sewer,etc.) type&use: ❑ Street(Plan,Profile) ❑ Water,Storm and Sanitary(Plan Profile) ❑ Water Quality Facilities ❑ Grading ❑ Landscaping/Tree Plan ❑ Composite Utility Plan(Electrical,Phone,Gas, Storm, Sanitary,Water,Signage,Street Lights,etc.) ❑ Details ❑ Traffic Sight Distance ❑ Signing and Striping ❑ Street Light Plan and Photometric ❑ Engineers seal/signature ❑ Sheet label(project land use name,revision and plan log block,dates and sheet numbers.) ❑ Engineer's Construction Estimate Additional Submittals (per land use conditions,if applicable) ❑ Traffic Report ❑ Storm water Drainage Calculations ❑ Geotechnical Report ❑ Preliminary Access Report(Sight Distance) ❑ Proposed Plat ❑ Pathway Design ❑ Water Provider Approval City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 3 of 4 9 s'w •• y- '• S I Edge of Pavement -46— Ditch �•� QStreetlight —•—•—•—•—•—•-r-•- / •{ �1 x.ir,Draina. ® I a r 1 • T—'�roposrd•Sewi— rriiiig-- 1 4.I I 1 I NI ! Existing House Yr 1 Existing 1 �I >r • Driveway NI op :1 al .sir/;rl d1 I r1 a v 1 II • 1 Existing Shop 1 cA •J ` , • Powerpole I .--t-' I f 1 cn • 0 '�`■ I a 95' �--•—•--'lrroper Line—•--- ! IN Ia 1 Fire Hydrant(FH) I I II Scale: 1"=30' I 1 I I 1 I I I TYPE 1 AND TYPE 2: MINIUM SKETCH REQUIREMENTS (Put N/A if not applicable) North arrow Property lines&dimensions Existing utilities locations (sewer,storm,water) Street& street names All existing structures Proposed work Existing curb or edge of pavement Utility&street light poles Existing S/W or D/W apron Slope of property Trees City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 4 of 4 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT IIIs COMMUNITY DEVELOPMENT Permit#: PFl2019-00164 T[GARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 05/29/2019 Parcel: SEG2468 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: CenturyLink Project Description: Adjacent to 16037 SW Upper Boones Ferry Rd. Bore and place 165'of 1-2"conduit along and across SW Upper Boones Ferry Rd near SW 72nd Ave. Owner: FEES Description Date Amount PFI Permit Fee 05/29/2019 $300.00 PHONE: Contractor: PHONE: FAX: Applicant: SCOTT MILLER 8021 SW CAPITOL HILL RD, SUITE 110 PORTLAND, OR 97219 PHONE: 503-242-4144 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 A Signature: 5CC- uppCjca• v. lk Issued By: r (%e. L._. Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PFI2019-00164 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 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_Utilities 09-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 10-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 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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. PFI_Utilities 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_Utilities 22-DAILY INSPECTION REPORTS Applied Notice Applicant shall submit daily inspection reports, on a weekly basis, to the City's Inspector. PFI_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 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_Utilities 28-AS-BUILT DRAWING Applied Notice 1,2,3,4,5 28-AS-BUILT DRAWING 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). 1,2,3,4,5 28-AS-BUILT DRAWING 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). 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_Utilities 31 -OTHER Applied Notice Other RECEIVED City of Tigard MAY 2 $ 2019 - "� PUBLIC WORKS—ENGINEERING CITY OF TIGARD IN 1'l f:;f'�RD Public Facility•ty Improvement (PFTh 'NG ea�� a _� �,a^tea_. _.W �.:z_ ...__ .�•.-., ���: d _ TYPE OF WORK DESCRIPTION OF WORK(in the right-of-way) ® TYPE 1-Franchise Utility Work Check one: ❑x Utilities ❑Sidewalk/driveway approach 0 Streetimprovements performed by NWN, PGE Detailed description: and/or utility agency. Bore and place 165'of 1-7 conduit along and across SW Upper Boones Ferry Rd 0 TYPE 2—Sidewalk/Driveway/Sewer near SW 72nd Ave Work performed for the purpose of • Sidewalk installation or repair. 16037 SW Upper Boones Ferry Rd ' Driveway approach installation Property address/location(s): /1`/AI and/or repair -S7V__ .2 b • Sanitary sewer lateral installation and/or main line tap CenturyLink 1:1 TYPE 3—Pull scale Development Applicant Work performed with Land use Address: 8021 SW Capitol Hill Rd,Room 110 approval which includes any of City/state: Portland,OR zip: 97219 the following: Phone: F.mail: Scott.Miller4f(centurylirtk.com • Subdivisions or Partitions Scott Miller 503-242-4144 • Street widening Contact name: Phone: • Mainline installation for Sanitary Contractor. C-2 Utilities LLC sewer,Storm sewer,Tigard water and/or Tigard Water Service Area CCB#: 154786 Expiration: Address: 11618 NE Sumner St,Suite a SUBMIT COMPLETED APPLICATION TO: City/state: Portland,OR Zip: 97220 City of Tigard Phone: Email: bhelberg@o-2utllity.com Planning/Engineering 13125 SW Hall Blvd. Contact name: Bruce Heiberg Phone: 503-772-1878 Tigard,OR 97223 Applications for"minor work in right-of-way" only may be emailed to: Engineer: rowpermita@tigard-or.gov Address: I &tR -,1 Al I I '1 ONI,1 City/state: Zip: Phone: Email: Case No.: 1P/ 20/q- 00/iD171 Contact name: Application submittal fee(.07%of Engineer's Estimate) $ Estimated value of work is required(if over$5,000):$ 9599.00 Additional fees: $ 3 00 (within the public right-of-way) Applicatizrepted: /� By: f Date: e ll_9 Is work related to a LAND-USE DECISION? ❑ Yes ® No Application reviewed: If so,please specify(MLP,SDR,SUB,etc) case#: By: Fr'6 Date: 5-/2 TM Is work related to a BUILDING PERMIT? 0 Yes © No Applicant notified: If so,please specify(BUILDING PERMIT)case#: By: Al./ Date:IWO_ rAENG\PermkApptcatbns\pk eppratbn Effective 10/16/2017 City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-orgov • 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 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. David Dodd 05/21/19 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 • wwwtigard-or.gov • 503-718-2421 • Page 2 of 4 DEVELOPMENT ENGINEERING FEES FOR srAl 1 t SE: 0y1A Public Facility Improvement(PFI)Permit: DETAILED St'BMITTAL APPLICATION FEE RE;QL IRL;MENl'S Part 1: Required submittal fee$300.00 FRANCHISE UTILITY AND SIDEWALK/ PERMIT FEE DRIVEWAY AND UTILITY Part 2: All non-water system improvements CONNECTIONS,ETC. Engineer's estimate X 5%(less$300.00 submittal fee) (work in the right of way) Engineer's estimate X 2%Plan Review Sketch (including information below) WATER SYSTEM FEE ❑ Dimensions Part 3: All public water system improvements ❑ Street Name Engineer's estimate X 12% El Site Address PFI Permit Fee Exemptions: FULL SCALE DEVELOPMENT There will be no permit fee charged,or assurance required for the following types of work: (Subdivisions/Partitions and Street Improvements) • Sidewalk repair(less than 20 lineal feet) • Relocate or replace mailbox Design Plans • Ditch leaning that does not involve regrading. (6 sets,2406 or 22x34) • Weep hole repair ❑ Cover—Site,Vicinity,Abbreviation,Legend • Curb repair or replacement(less than 20 lineal feet) ❑ General Notes(City,Water,Sewer,etc.) • Lawn sprinkler system installation or repair 0 Street(Plan,Profile) • Street tree pruning or planting ❑ Water,Storm and Sanitary(Plan Profile) • Planter strip landscape maintenance 0 Water.Quality Facilities • Test wells 0 Grading ❑ Landscaping/Tree Plan ❑ Composite Utility Plan(Electrical,Phone,Gas, Note: A cash assurance may be required per Storm,Sanitary,Water,Signage,Street Lights,etc) TMC 15.04.140.(customer deposit) ❑ Details ❑ Traffic Sight Distance ❑ Signing and Striping ❑ 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 El Pathway Design(if applicable) ❑ Water Department Approval ❑ Engineer's Construction Estimate PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 3 of 4 SAMPLE SKETCH: 9 SW "y " St, Edge of Pavement ".'� Ditch ��` Streetlight •—•...........•—•-.-•am.. mow.- 4 ./...I 7 Duda 01,,-1.. 0 ):( 1'---- l • I 1 � . Existing House I ?aY,! 1 dl 31 01 1 L ' •` II l - I -� ' 1 a1 R i t-1 1 I G.,' rI o� 1 gI 1 IcN 1 Existing Shop 1 Powe� � .\ rp�ol'e' I = (a a _ � . n is 95' 1 p-------157opertytJne-- —.—.—. 1 Fire Hydrant(FH) I I I ! Scale: 1=30' i I • I ! . f I I . MINIMUM SKETCH REQUIREMENTS (Put"N/A"if Not Applicable): North arrow Property lines&dimension Slope of property Street &street name(s) Existing building, structures Utility&street light poles Proposed work Rxivting 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 • wwwtigard-or.gov • 503-718-2421 • Page 4 of 4 COMMUNIC,e).S .' A CENTURYLINK C t,_N MOW 11 ,67 BORE AND PL/ Q TO EXISTING I 'y PASS THROUG I'c CONDUIT TO ( BUILDING • •5SN >s\ A .'0) &.tt,. \ ,,,,..--,, )1\1-- - .'` ,--34,, ,6 4•1 1 i, Q - 'Q , v:,-- z,z, IU TO FOLLOW ,_., ..^_./..1,...,..,11k. I TfWNSHTP: PS I DESIGNED BY: CHRIS MCKISSICK PROJECT: N,5( / / \4 Q- / 1 TO 41 ''14:16 / 4 <302c . 5 eg 16045 /e), �,r A'` )� / y ^nni` / ��� -7 d- R MH N!' 44 -• / s 0 EXSTING H �i. �s6'= s roe �j, ® 105' •�*• / 1110. S4* ",c� \ BORE AND PLACE �%� % 1 -2 HDPE ZO ��� ��.,� v .� FoA (MIN 36"_ DEPTH 14 ��� "'� Eoe L � . ‘, \ 1). / / y t,•• . • SL 's 4,4s. / R/W // ik s`� _ /,S C�_ \ �j s'� .5 V3-- ,�� i p c3 / ,r4..1 0 4 FT'' NI/ k 4 'x4' s� \ BOREPIT %- 4- /‘r s'N' C> 60' LP- // :ORE AND PLACE 3048HH PLACED Ok �S 1 -2" HDPE ON N.47734' 'GE # 1752 (MIN 36" DEPTH) . EXISTING 2" CONDUIT / PLACED ON N.477349 • i . ."'"? ` • 47 Mr 3s 50 �f6d .. ,i 1111114111Stssio# > 4401 .,.,,,,s.,,,,,,,,,_ 4 ' 1 % --. f • 7 -`' ( 32 1 1 Inside Dimensions L j' Width Depth 5 13tW 28 3/16' ' 1 36131W 3116* sw; i.� RJ TO FOLLOW I T^ I DESIGNED BY: CHRIS MCKISSICK PROJECT, N,5 I♦ a/" 1 I T," I" t1 au r uv and u/i CH ZU7 7 plan andu A,1@ if maul/Or MM.approval. f�� OCp/ v R3 Irds. Ref.MUTCD 2009 6A-01(10) -r y o per 20 (NOT TO SCALE // 4t? ® Re PP 9r tapers equal to the J Ty f speed.20'min.for tangent JQ rnreeis 16037 aW y y � ®W fns w/Flags r/ stop signs and/or disable vhen at a controlled intersection Existing Hand ole No Parking signs 48 hrs in advance. to field conditions. .. El .■■► • • , ,,1/4 t. ,e s Bore guide - fr N. to cross 3 • with crosswalk signal •::. 7U' Bore Pit • ° di' INVENT • . o' • ore Path a 5 Road 350' 1 Lane 7 '.,. 1 Centi 30. 78HH 1 Right 1 Type ot,1000000000,ii.. . 35 Con •. ROAD • • ��rWORK • \ 41. HEA. . .or/ cn V PEE N 350' Lam a `35