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PFI2019-00317 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT 114 = COMMUNITY DEVELOPMENT Permit#: PF12019-00317 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 09/19/2019 TtGARI? Parcel: SEG1859 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: Comcast Plant Extension Project Description: SEG1859//14050 SW Milton Ct. Bore to place(1)-2"conduit a min 36"below grade and place new pedestal. Class of Work: FEES Description Date Amount Type 1 Utilities(gas, electric, data) PFI Permit Fee 09/19/2019 $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.tigard-or.gov to schedule inspections online. Contractor: PHONE: Applicant: ALEX SILANTIEV TIGARD, OR 97223 PHONE: 5035963733 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 See application Signature: Issued By: �— Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PFI2019-00317 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[OUCH]. 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 RECENED SEP 1 9 2019 p INIcity of Tigard CITY OF TIGARD PFI#: f PZ�1y-°°3 1� f ENGINEERING DEPARTMENT PI-ANNING/ENGINEERING TIC, i• I Public Facilities Improvement (PFI) Permit PROJECT INFORMATION TYPE OF WORK Project name: Comcast Plant Extension - SHB Power j 0 TYPE 1—Franrhim Utility Work Brief description of project: Bore to place (1)-2" conduit a min of performed by N' 1'l,PGE, or utility agency 36" below grade and place new pedestal. o TYPE 2—ROW Sidcwalk/Driveway/Sewer Work performed for the purpose of: • Sidewalk installation or repair • Driveway approach installation and repair SITE INFORMATION • Sanitary sewer lateral installation and 14050 SW Milton Ct, Portland, OR 97224 main line tap Location (address if available): 0 TYPE 3—Full Scale Development Work (—_,G 1 S91 performed with land use approval which includes any of the following: • Subdivisions or Partitions APPLICANT INFORMATION • Street widening Comcast • Mainline installation for sanitary sewer, Name: storm sewer, Tigard water, and Tigard Mailing address: 11308 SW 68th Parkway water service area City/State: Tigard, ORZip: 97223 0 TYPE 4—Small Cell Technology Phone: (503) 596-3733 0 TYPE 5—Tigard Triangle Alexander Silantiev comcast.com Email: — @ Phone: NOTE: Type t and 2 applications may be Alex Silantiev emailed to piupcnnitsk tigard-orpix. Contact name: Phone: (503) 941-8656 Email: Alexander_Silantiev@comcast.com CONTRACTOR INFORMATION 0 Same as applicant Name: Texstar Enterprises CCB Number: 178798 Mailing address: 14122 Arndt Rd City/State: Aurora, OR Zip: 97002 Phone: (503) 793-3109 Email: Jim.miner@texstarenterprises.com ENGINEER INFORMATION Name: K&B Technical Solutions Mailing address: PO BOX 2529 Cir)/State: Clackamas, OR Zip. 97015 Phone: (503) 650-6041 Email: Corey_Dunston@kbmail.net ADDITIONAL INFORMATION Estimated value of work is required(if over$5,000):$ (within the public right-of-way) Is work related to a LAND USE DECISION? 0 Yes 0 No Case number: City of Tigard • 13125 S\V Hall Blvd. • Tigard,Oregon 97223 • www.tigard-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 I Accused 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. Corey Dunston 9-19-19 App ' s or authorized agent's signature Print name Date Property owner's signature (if required) Print name Date STAFF USE ONLY Case No: 19F-17,6IQ—60;1/- Permit fee: 300-X' Received by: ' t' Date: t""1 _i Approved by: 7. ei i7"S Date: 9/9/eW,' Notified by: /•—•Z Date: / l9 City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-otgov • 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 PH 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 PH 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? 0 Yes 0 No TYPE 1 AND TYPE 2-Must include a sketch showing: Under the wireless facilities standards,is the proposal 0 Dimensions considered?(check all that apply): 0 Small Cell 0 Macro ❑ Street Name ❑ Site Address How many install sites are proposed as part of this permit 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: 0 Public Right-of-Way 0 Private Property ❑ Cover—Site,Vicinity,Abbreviation,Legend If equipment is to be located on private property,describe the 0 General Notes(City,Water,Sewer,etc.) type&use: 0 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 El 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 • www.tigard-orgov • 503-718-2421 • Page 3 of 4 Z1 O � 5N Z 0 r .,O A z is os , , DESCRIPTION: EXAMPLE DESCRIPTION: EXAMPLE: CO o '-W Z F CCEl 1W� 2 BORE/DRILL —..-.._..-.._..-..— JOINT USE POLE v a TRENCH JOINT USE POLE WI TRANSFORMER 0 / EXISTING CONDUIT POWER POLE W/TRANSFORMER Z 0 STRAND POWER POLE RIGHT OF WAY CABLE POLE • PROPERTY LINE TELEPHONE POLE 9 1 ee • • • 1 PUBLIC UTILITY EASEMENT ------- PEDESTAL.VAULT ® © I u . . . CENTER LINE ---u--- MANHOLE FACE OF CURB - - CATCH BASIN mom EDGE OF PAVEMENT VALVE(WATER,GAS,ETC) 0q i EDGE OF GRAVEL METER(WATER GAS.ETC) O➢ x g g EDGE OF SIDEWALK - FIRE HYDRANT 'N 11 EDGE OF DRIVEWAY - REMOVE 8 a , REPLACE LIMITS. $_:- BORE PIT ISEWER S ! STORM _. .. a B WATER .__. _. 61 GAS -- a 4 <I 9-,'8, POWER ? Xi8 TELECOMMUNICATION - ~ g I R. CAN - - TRAFFIC CONDUIT -- -- E v STEAM NS 1 FENCE UNE —.—.—.—.— E u GUARD RAIL - wVI U m F 6 RAILROAD TRACKS nunnnnnunununm ..m 0 Ou' I 1 a I I SHEET MO RP-L PE ,10 CMEX•29733-10712 \ S\ \ \ \ CS any/� / \ N NN(1' E 0 CV \ / \ \\ ,y ot‘ .,,.,‘ \ \.S� oo ^tea V �W0 \ �o ND CONSTRUCTION AT PROPOSED PEDESTAL \ SCALE: 1"=30' o 1' m RQ' J \ mm \ \ 59 \\ U 0 qy i \ \ /IV/ 14050 \ V e REMOVE AND REPLACE(1}5'X6'FLAG ` ¢ ` (\ \ OF SIDEWALK FOR BORE PIT \\ i 1 1 • . •\ _ \ ���� 14058 \ Z B i k,-\,\ ,, i „,..,„---''''C.\,..\ NI .\,,c ..-- \ \-"7-'\ ‘ ,, z BORE TO PLACEn}r corouT g .'7.\ ' ; 9''\4 A MM OF 38'BELOW GRADE \ e . g..z • \ t 4 U x \ '•\ \ 7---• • \,1\4, / • ° REMOVE AND REPLACE(1}57(6' Aja\ • FUG OF SIDEWALK FOR BORE PT \ `i t �� BEGIN CONSTRUCTION AT EXISTING ! (' UTILITY POLE IN CITY OF TIGARD ROW S ��\ Nc V \\\ \,\ Kg�\ $ 14118 y QN E % ¢ \--. V 2c OS.o 9Z` U�s 11 \ LI:,,\ \ 31 \ \\\\\\ 1 ALL WORK AREAS TO BE RESTORED TO LIKE OR BETTER SHEET NO ''\\1, Y \ 19 le CONDITION. 1 \ \\ �\` \\\\ _ _ 2.ALL OTHER UTILITIES ARE BASED OFF EXISTING LOCATES RP lY ~\ \\4 OR UTILITY STRUCTURES. 3,IT IS THE CONSTRUCTOR CONTRACTORS PERMIT No .::,,..r..:.,,,,....,...., RESPONSIBILITY TO CALL FOR LOCATES BEFORE DIGGING. CMEX-29763-10712 2011 Edition Page 81 Shoulder Work w/ Minor Road Encroachment Diag. 300 „40::)\.\, WORKALt: AHEAD • Initial Warning A • Sign • it • • (Optional) • • • • • • (I N . L • 111• 1 Protection Vehicle w/TMA(both Optional) See Chapter 4 - • 1 Buffer • 10' • minimum • 1-J3 • A ROAD NARROWS V (Optional) B 1 t w___ _ ___(„, ROAD WORK AHEAD Initial Warning Sign September 2016 Chapter 5 Page 80 2011 Edition 5.3 Two-Lane, Two-Way Roads Shoulder Work w/ Minor Road Encroachment Diag. 300 Use this detail for non-freeway work which extends into a travel lane and maintains a minimum 10 foot travel lane. If a minimum 10 foot travel lane cannot be maintained, or when traffic cannot safely pass by in both lanes simultaneously, use the appropriate lane closure diagrams—for example, Diagrams 310 through 350. A lane closure may be appropriate for conditions such as high traffic volumes, high speeds, and inadequate approach sight distance to the work space, or heavy equipment adjacent to the travel lane. 1. Use truck-mounted flashing warning lights on work and protection vehicles. See Section 4.3—Lights and Lighted Signs for exceptions. 2. For added visibility, a truck-mounted arrow board or PCMS in caution mode may be used. 3. Cones shall be placed along the entire length of the work space. If a protection vehicle is used and work is in place one hour or less, the taper and tangent devices may be omitted. 4. If the speed is 45 mph or higher, volumes exceed 2000 ADT, or there is limited sight distance, consider placing cones or tubular markers on centerline. 5. An arrow board in caution mode or truck-mounted PCMS with "SHOULDER WORK"or other appropriate message may be used for higher visibility. Sign Spacing and Buffer Lengths(feet) Posted Spacing Between Signs "Buffer" Speed A B C Space 20 50 25 100 100 100 75 30 100 35 125 350 350 350 40 150 45 180 50 500 500 500 210 55 250 60 285 65 700 700 700 325 70 365 Chapter 5 September 2016 114 . . : TIGARD City of Tigard November 8,2019 K& B Technical Solutions PO Box 2529 Clackamas, OR 97015 Re: Permit No. PFI2019-00317 Dear Applicant: The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the following: Site Address: N/A Project Name: Comcast Plant Extension Job No.: N/A Refund Method: ® Check#233842 in the amount of$240.00. ❑ Credit card "return"receipt in the amount of$ . Note: Please allow 2-5 days for this refund transaction to be credited to your account by the company that issued your card. ❑ Trust account"deposit"receipt in the amount of$ . Comment(s): Per applicant's request as job was cancelled. Refund 80% of permit fees as plan review was completed and permit was issued. If you have any questions please contact me at 503.718.2430. Sincerely, Dianna Howse Building Division Services Supervisor Enc. 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171 TTY Relay: 503.684.2772 • www.tigard-or.gov II City of Tigard T icAiiu Accela Refund Request This form is used for refund requests of land use, development engineering and building permit application fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached to this request form. Refund requests are due to Accela System Administrator by each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts Payable will route refund checks to Accela System Administrator for distribution to applicant. PAYABLE TO: K&B Technical Solutions DATE: 11/1/2019 PO Box 2529 Clackamas, OR 97015 REQUESTED BY: Dianna Howse TRANSACTION INFORMATION: Receipt#: 425929 Case#: PFI2019-00317 Date: 9/19/2019 Address/Parcel: Pay Method: CreditCard Project Name: Comcast Plant Extension EXPLANATION: Per applicant's request as job was cancelled. Refund 80% of permit fees as permit was reviewed and issued. REFUND INFORMATIONc Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 2300000-43104 $Amount PFI Permit Fee 640-0000-43114 $240.00 TOTAL REFUND: $240.00 APPROVALS: SIGN DATE: If under$5,000 Professional Staff s �_ If under$12,500 Division Manager If under$25,000 Department Manager If under$100,000 City Manager If over$50,000 Local Contract Review Board FOR ACCELA SYSTEM ADMINISTRATION USE ONLY Case Refund Processed: Date: qp_At By:J1A I:\Building\Refunds\RefundRequest.doc x 09/01/2010 CITY OF TIGARD RECEIPT ■ 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 TIGARD Project Name: Comcast Plant Extension /J ` / Site Address: 1675.[ fV/' Receipt Number: 436192 - 09/03/2021 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12019-00317 $-240.00 Total: $-240.00 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Check 233842 DHOWSE 09/03/2021 $-240.00 Payor: K&B Technical Solutions Total Payments: $-240.00 Balance Due: $240.00 Page 1 of 1 liftCITY OF TIGARD RECEIPT s •• 13125 SW Hall Blvd.,Tigard OR 97223 503.639.4171 T[GA1'1) Project Name: Comcast Plant Extension Site Address: ii-/PA/e - Receipt Number: 425929 - 09/19/2019 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID PF12019-00317 PR Permit Fee 640-0000-43114 $300.00 Total: $300.00 PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT Credit Card 5577579 PUBLICUSERO 09/19/2019 $300.00 Payor: Total Payments: $300.00 Balance Due: $0.00 Page 1 of 1 RECEIVED City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT OCT 1 1 2019 1111 Request for Permit Action CITY OF TIGARL' PLANNING/ENGINEERINt. I i t;, 13125 SW Hall Blvd. • Tigard,Oregon 97223 • 503-718-2439 • www.tigard-or.gov TO: CITY OF TIGARD V 0 Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 f/////9 Tel'— Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigar�cJJ- gov FROM: ❑ Owner Er4plicant ❑ Contractor ❑ City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) 1E.36(�j Te C hnicc,‘ 50 itrti ' Y>s -W 1 C)'4.(1 Si v nrH{- Mailing Address: eo 64:5x 2529 City/State/Zip: G>,pxa yvtots 0` - GI 1 O 1 S Phone No.: 503 (c'50 (CO LI 1 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ❑�/ CANCEL/VOID PERMIT APPLICATION. L2J REFUND PERMIT FEES(attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE(attach case fee schedule and provide explanation below). Permit#: /f.J".7o/> - i '>.i/ 7 Site Address or Parcel#: / 5 ' Sc✓ /4'7/ tort/ Project Name: Goy<asi 5 Subdivision Name: Lot #: EXPLANATION: � rT fi.es /' j�zcnf tJ t�0 °Id t97 fail/T t4/es .LE7/>EZJE7 . /Sfuc�i Signature: Date: // '/7 49 Print Name: &fluid Policy 1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of • Any 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. FOR OFFICE USE ONLY Route to Sys Admin: Date By Route to Records; Date 9 1 : ./,/ Refund Processed: Date ///j// 9 By,(et&,_ Invoice Processed: Date By Permit Canceled: Date // f// P By icel Tag Added: Date By I:\Building\Fonns\ttegPermitnction_12b5l8doc --- _-. Michelle Simnitt From: PayGov <no-reply@paygov.us> Sent: Thursday, September 19, 2019 1:54 PM To: Michelle Simnitt Subject: Order Receipt 5577579 This email is a confirmation of your Online Payment for PERMIT CENTER Cardholder Name: Michelle Simnitt Telephone : : (503)650-6041 Credit Card Type : Visa Last 4 digits : 4XXX XXXX XXXX 0552 Confirmation Number : 5577579 Card Auth Code : 519145 Transaction ID : 1592539692 Agency Payment Amount : $300.00 Convenience Fee : $9.00 Total Amount Charged : $309.00 First Name:Michelle Last Name:Simnitt Your payment to PERMIT CENTER has been processed by PayGov, LLC. NOTICE.Two charges will appear on your credit card or bank statement. One is for the Tax,Fine, or Fee owed to the government agency and will reflect the name of the agency. The other is for the convenience fee assessed by PayGOV.US and will reflect"Convenience Fee"on your statement. For questions or concerns contact PayGOV.US at 1-866-480-8552. Transaction disputes will result in a$40 charge to the cardholder. 1 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit*: PFI2019-00317 T[GAA.D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 09/19/2019 Parcel: SEG1859 Jurisdiction: Tigard Site address: V 0 I D Subdivision: Lot: Project: Comcast Plant Extension Project Description: SEG1859// 14050 SW Milton Ct. Bore to place(1)-2"conduit a min 36"below grade and place new pedestal. Class of Work: FEES Description Date Amount Type 1 -Utilities(gas,electric,data) PFI Permit Fee 09/19/2019 $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.tiaard-or.gov to schedule inspections online. Contractor: PHONE: Applicant: TLEX SOILANTIEVTIGARD, 03 979637 PHONE:5035963733 CO y. 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. PermitteelApplicant See application Signature: Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PFI2019-00317 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 IATSSA],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 REc : \! 0 1 D II ih, City of Tigard CI Y O iGA D PFI #: Pri l�-r�OJI� ;i 2 ENGINEERING DEPARTMENT PLANNING/ENGINEERING TIGARD Public Facilities Improvement (PFI) Permit PROJECT INFORMATION Comcast Plant Extension - SHB Power TYPE OF WORK Project name: ❑ TYPE 1—Prarchise Utility Work Brief description of project: Bore to place (1)-2" conduit a min of performed by N\XN,POE, or utility agency 36" below grade and place new pedestal. o TYPE 2—Ili(,WSidewalk/Driveway/Sewer Work performed for the purpose of: • Sidewalk installation or repair • Driveway approach installation and repair SITE INFORMATION • Sanitary sewer lateral installation and Location (address if available): 14050 SW Milton Ct, Portland, OR 97224 main line tap { 0 TYPE 3—full Scale Development Work _,G l2S`j performed with land use approval which includes any of the following: • Subdivisions or Partitions APPLICANT INFORMATION • Street widening Name: COmCaSt • Mainline installation for sanitary sewer, storm sewer, 'Tigard water, and Tigard Mailing address: 11308 SW 68th Parkway water service area City/State: Zip.. Tigard, OR 97223 0 TYPE 4—Small Cell Technology Phone: (503) 596 3733 0 TYPE 5—'I'igard'triangle Email: Alexander_Silantiev@comcast.com Phone: NOTE: Type I and 2 applications may be Contact name: Alex Silantiev mailed to rowpermitsC itipard-ur,rov. Phone: (503) 941-8656 Email: Alexander_Silantiev@comcast.com CONTRACTOR INFORMATION 0 Same as applicant Name: Texstar Enterprises CCB Number: 178798 Mailing address: 14122 Arndt Rd City/State: Aurora, OR Zip: 97002 Phone: (503) 793-3109 Email: Jim.miner@texstarenterprises.com ENGINEER INFORMATION Name: K&B Technical Solutions Mailing address: PO BOX 2529 City/State: Clackamas, OR Zip: 97015 Phone: (503) 650-6041 Email: Corey_Dunston@kbmail.net ADDITIONAL INFORMATION Estimated value of work is required(if over$5,000):$ (within the public right-of-way) Is work related to a LAND USE DECISION? ❑Yes 0 No Case number: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page I 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 putsuant to a valid franchise or license with the City of Tigard,when the owner and the applicant arc 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 rwner. The owner must sign this application in the space provided or submit a written authorization with this application. Franchised or licensed Utilities arc not required to obtain the tnvner s signature on the application. 1,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. Corey Dunston 9-19-19 — App' s or authorized agent's signature Print name Date Property owner's signature (if required) Print name Date r 7 A F USE ONLY (((///�����/ Case No: Pt l2 IQ-I131�� Permit fee: c Received by:•Date: j i Approved by: �YYhff�. Date: I/PiVegW, Notified by: Date: /g City of Tigard • 13125 S\\'I fall Blvd. • Tigard,Oregon 97223 • wwwtigard-oegov • 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: AU 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 LSL O:ALV FOR SIAH L L UNL TYPE 4: SMALL WIRELESS FACILITY TYPE 1—3:DETAILED SUBMITTAL CHECKLIST REQUIREMENTS Does applicant have a right-of-way license? ❑Yes 0 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 ❑ Site Address How many install sites are proposed as part of this permit 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: 0 Public Right-of-Way 0 Private Property D 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 Fealties ❑ 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 O 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) O Proposed Plat ❑ Pathway Design ❑ Water Provider Approval City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 3 of 4 hY. 1O °1 3� � s a DESCRIPTION: EXAMPLE: DESCRIPTION: EXAMPLE g IE 2 qq ww BORE/DRILL —__.._.._.._.._.._ JOINT LBE POLE X 03 W TRENCH JOINT USE POLE WI TRANSFORMER D 3� _I E)GSIWCOMM'G CO POWER POLE WI TRANSFORMER U STRAND — - POWER POLE RIGHT OF WAY CABLE POLE • PROPERTY LINE TELEPHONE POLE PUBLIC UTILITY EASEMENT ---. - PEDESTAL,VAULT m m i 1 9 . . . CENTERLINE ---)— WHOLE Ea FACE OFCURB CATCH BASIN cm 1 EDGE OF PAVEMENT VALVE(WATER GAS.ETC) PS k . WOE OF GRAVEL - METER(WATER.GAS.ETC) GI ps9 tS EDGE OF SIDEWALK FIRE HYDRANT — EDGE OF DRNEWAY REMOVE•REPLACE B E AJELER BORE PIT B r SEWER g ` STORM -- - g WATER GAS , Y POWER _. 1 IS TPAGVAISMA IIMPAnON _____ CATV . 8 R TRAFFIC CONDUIT — STEAM —.—— o (1)i S y FENCE UNE al GUARD RAILa"a 8 IPT'ia l RAILROAD TRACKS � N a ON RP-L G EX-297BiIO7l2 • • \ / \\ 2 / ''' \� N O8 s \ + q ik / \ o u�. \ /( y CONSTRUCTION AT PROPOSED PEDESTAL \ SCALE: 1',30' 1 1I$1 �I 1 = /iI uoso \ U 1 \ \ \ REM 15'X5 REMOVE AND REPLACE FLAG \\ llllOF8IDEWAK FOR BOEWT I RI ; \ \ \\ 14055 / \ /, \ \ G. a .V \ wdIE m FLACE(1fr CDwurr \ s , \\ AMMOFSBELow GRADE e21ll1 I1\ N \ll // 8 I1I1' \-\\ REMOVE AND REPLACE 11}5'XB' �O �\. FLAG OF SIDEWALK FOR BORE RR Fa 2 MGM CONSTRUCTION AT EXISTING I— g UTILITY ROLE N CITY OF TIGMW ROW \ �./1 ¢ � c ♦g 1N18 4 w ''''‘\ \ \ 1C ALL WORK AREAS TO BE RESTORED TO LIKE OR SEETER ��� 11 \\�\ \ U ! T\L \ \\ ___ _se 2.ALL OTHER trnovEs OR UTILRY STRUCTURES BASED OFF EXISTING LOCATES \k 3.IT IS THE CONSTRUCTION CONTRACTORS �rp ..w,.„..N..,. RESPONS$BRV TO CALL FOR LOCATES BEFORE DIGGING. 1.10112 2011 Edition Page 81 Shoulder Work wl Minor Road Encroachment Diag. 300 ,. ROAD 1• WORK j-A, AHEAD • Initial Warning A • Sign H.• ( . • • • • �► fill • , Protection Vehicle w/TMA(both Optional) See Chapter 4 • Buffer • 10' • minimum • • A /ROAD NARROWSj (Optional) j I 1 _ ROAD C v _ 1 WORK ��,AHEAD Initial Warning Sign September 2016 Chapter 5 Page 80 2011 Edition 5.3 Two-Lane, Two-Way Roads Shoulder Work w! Minor Road Encroachment Diag. 300 Use this detail for non-freeway work which extends into a travel lane and maintains a minimum 10 foot travel lane. If a minimum 10 foot travel lane cannot be maintained, or when traffic cannot safely pass by in both lanes simultaneously, use the appropriate lane closure diagrams—for example, Diagrams 310 through 350. A lane closure may be appropriate for conditions such as high traffic volumes, high speeds, and inadequate approach sight distance to the work space, or heavy equipment adjacent to the travel lane. 1. Use truck-mounted flashing warning lights on work and protection vehicles. See Section 4.3—Lights and Lighted Signs for exceptions. 2. For added visibility, a truck-mounted arrow board or PCMS in caution mode may be used. 3. Cones shall be placed along the entire length of the work space. If a protection vehicle is used and work is in place one hour or less, the taper and tangent devices may be omitted. 4. If the speed is 45 mph or higher, volumes exceed 2000 ADT, or there is limited sight distance, consider placing cones or tubular markers on centerline. j 5. An arrow board in caution mode or truck-mounted PCMS with "SHOULDER WORK"or other appropriate message may be used for higher visibility. Sign Spacing and Buffer Lengths Ifeeti Posted Spacing Between Signs "Buffer" Speed A B C Space 20 50 25 100 100 100 75 30 100 35 125 350 350 350 40 150 45 180 50 500 500 500 210 55 250 60 285 65 700 700 700 325 70 365 Chapter 5 September 2016