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PFI2019-00252 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENA ! CI I lig _ Request for Permit Action #II/ 3 l9 q °/� T I G A R 1) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner ,Applicant ❑ Contractor S, City Staff Check(1)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): ,,!' CANCEL/VOID PERMIT APPLICATION. REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). Permit#: W I20Y_CD`zS 2— Site Site Address or Parcel#: 23 Project Name: \t 'Jt Ort Wind. Subdivision Name: Lot#: EXPLANATION: A=eir M It n---,ii- rupAaj . N) ( n .-t-t C'LV ,jui h (.0 ►-A+`).--\ Signature: t ii \.. Date: 114L Print Name: Refund 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 • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended.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 800/0 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 /rj`3// i By ,� Refund Processed: Date A/ B�tQpl Invoice Processed: Date / By Permit Canceled: Date /p 3 f 9 BiY._.._.- Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_I 5 8.doc T °11VED V 0 1 9 � U ) 2019 fd/3/* 4.4.---. City of Tigard PFI#:2ti-coo 2s� ■ yr TIGARD • C ENGINEERING DEPARTMENTi IVIG/ENGINEERING TIGARD Public Facilities Improvement (PFI) Permit PROJECT INFORMATION TYPE OF WORK Project name: Washington Square - 100020148 ® TYPE 1-Franchise Utility Work performed by NWN,PGE, or utility Brief description of project: We will bore a 2 inch conduit between agency qreenburg and Washington Square rd. We are setting 2 vaults ❑ TYPE 2-ROW Sidewalk/Driveway/Sewer in the planter strip and entering the existing manhole to access Work performed for the purpose of: the building with the fiber. • Sidewalk installation or repair • Driveway approach installation and repair SITE INFORMATION • Sanitary sewer lateral installation and Location (address if available):9552 SW Oak St Tigard, OR 97223 main line tap � D TYPE 3-Full Scale Development Work -SE 2- I 1 1 -j` l performed with land use approval which includes any of the following: • Subdivisions or Partitions APPLICANT INFORMATION • Street widening Name: Phillip Fagin • Mainline installation for sanitary sewer, storm sewer, Tigard water, and Tigard Mailing address: 669 Glatt circle water service area City/State: Woodburn OR Zip: 97071 D TYPE a-Small Cell Technology Phone: 503 310 5340 0 TYPE 5-Tigard Triangle Email: pfagin@wavebroadband.com Phone: 503 310 5340 NOTE: Type 1 and 2 applications may be PhillipFaginemailed to rowpermits@tigard-or.gov. Contact name: Phone: 503 310 5340 Email: pfagin@wavebroadband.com CONTRACTOR INFORMATION ❑X Same as applicant Name: CCB Number: 211650 Mailing address: City/State: Zip: Phone: Email: ENGINEER INFORMATION Name: Phillip Fagin Mailing address: 669 Glatt circle City/State: Woodburn OR Zip: 97071 Phone: 503 310 5340 Email: pfagin@wavebroadband.com 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 tEl No Case number: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 1 of 4 c4 lit J Agp It 1-.447: (01004A t -VVs►4 r11- ,2d... 1 A -t--E. G-•YL I -i..t iS u25 /3 use+-S14 . C'tt/ - 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 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 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. Phillip Fagin 8/02/2019 A cant's o thorized agent's signature Print name Date Property owner's signature (if required) Print name Date STAFF USE ONLY Case No:Wa0i4'002j a' Permit fee: Received by: Al- Date: IS ISI tq Approved by: Date: Notified by: Date: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-otgov • 503-718-2421 • Page 2 of 4 Pervn ci- hr+ neecie 1116+ 961Ju ns' 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? 0 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 ❑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 ❑ 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 Atojrd 95855 SW Washington Square Rd Broadband Tigard, OR 97223 CONSTRUCTION NOTES: 1-ALL WORK AREAS TO BE RESTORED TO LIKE OR BETTER CONDITION. General Location Scope of Work 2-ALL OTHER UTILITIES ARE BASED OFF EXISTING LOCATES OR 0 j' -., .) , _ UTILITY STRUCTURES t' * �� '. \ - EXISTING CONDUIT= 1,709 3-IT IS THE CONSTRUCTION - BORE FOOTAGE = 800 CONTRACTORS RESPONSIBILITY 1%4'"••1. f e SW Washington Square Rd ;:,j - NEW VAULT= 2 TO CALL FOR LOCATES PRIOR 8'' •11 q TO DIGGING '."1"‘..•\� -,\ Yom ., , .. I:MM•fdaL �t t' ° m^"_; • 'r.,-: ' CONTACTS: ' 41, 4•� •aim Construction Manager- -.4.,,114 anager- Tt �� a r ?� N.' ;, �' _ Jeff McConville l 'e� - + jmcconville@wavebroadband.com ..?4-74.i.;'>: 1..1. -• .- - ; (503)318-9804 t<x "1 ,_ 1�, - Y Permit Tech-Phillip Fagin fi y:' pfagin@wavebroadband.com ca+ 1 , �,Ste' , r (503)310-5340 SITE ADDRESS/SECTION: Vicinity Map Legend/Symbology 9640-9552 SW Oak St Tigard,OR 97223 "'�� -- - e Packet Description ii 111111-.. �� '� e { -�4 --j- BORE PATH Pa•e • EXISTING CONDUIT 1 Cover page `� C -t„ 2_3 Bore path/Existing conduit � I, ��sa +. - a "7-.0- ' - VAULT 4 vault 10 }' I . I `1 , — l • • POLE I y , � J Arm, !, J '� 1 I A ® RISER -fa7.7/ 7— sp �! Zeat } ity -- � NO � "•-- " _ PAGE NUMBER PROJECT NUMBER ' ► f' •.\4.. ..,. 100020148 sr „ ` r ils PAGE 1 OF 4 N . • ' 44W i ;i E v The telco vault is located her 0 �—will be utilized it to push fiber through f o) to customer.!4,709') '' i zl W �' 102 / .:,.. - , .. „.„.. ._ ._.._ ____,,, , , ________ 4-:- -a- R"••=.. *--------.. . -: - - - N. ° \ / 40a4,e7 J > � , i tiii i p t,, / L° i / / I I Yr IF ' -----'''''''''.--- ", i of 1 i $ ( 'tk " \ / • it a f _\�. A, of to 1 ., �t / �` Dig a pit to sweep conduit and bore P° round the corner and head northwest 4 I / ! PAGE NUMBER CONTACTS: SITE ADDRESS PROJECT NUMBER Construction manager PermitTech Jeff McConville Phillip Fagin A 2 jmcconville@wavebroadband.com pfagin@wavebroadband.com 9640-9552 SW Oak St (503)318-9804 (503)310-5340 Broadband Tigard, OR 97223 100020148 PAGE 2 OF 4 L ' .. ' .frt iii/. ; .a - - ; , •,►* .P • „ ► f3 4, ... ,- , ,-, - . .. _, . .. .r a ... r ,,,. 40$ s,c„,,,, x --- ... , , i.e. .A'S H I N • I ,; ■- *-.7. 4 r�V1 . 3 - s . 4i 4 3 a ( i 9. ',. C? .' 3 .... • s �• , xsc`.� �=t:b, r II --, I 4 ! r .:, � '� r 0 1.4 , 1 , „.. .is - ; , : ' — 1 zof * .2s- -' .ti 6 *; - Anal j . . • ,,, ' 4 ” jOcris s_iliik, . ,,,p, , „ 1 - f; . ,.., + *: • ."" •••• A - 4 . , c= X111!' 3 } RR is, , , ,,,„,,,t - ., . -1. -,,,, . ii3 . .4 : 410,bi . - %.. . Alit, . 10 - �'" ShL . _ txisti eico vault Apr . t ng ' " ' * It ,, * 'r` 1. le- ----7-441 iiii. ,. L___ s tel' o` PAGE NUMBER CONTACTS: SITE ADDRES PROJECT NUMBER Construction manager Permit Tech Jeff McConville PhillipFa in Astound 9 3 •mcconville@wavebroadband.com pfagin@wavebroadband.com 9640-9552 SW Oak St (503)318-9804 (503)310-5340 Broadband Tigard, OR 97223 100020148 PAGE 3 OF 4 N FCA243624T-00006 w E Ve eV FIBERGLASS/POLYMER CONCRETE ASSEMBLY s 24'x36"x 24" (For actual dimensions see draverg) 1 Fiberglass/Polymer Concrete Assembly. `6 Tapered Sides.No Floor.WUC 3 6- -'_- "20K,"3/8-Hex Bolts.Standard 24- Nameplate(Specify at time of order 35 y4 Installed LOAD RATINGS 11 �--.. Incidental Traffic-Parking Lot Sidewalk Conforms to 4 • VUC36 •ASTM C 857 ° � I 4 °,- ' •ANSI/SCTE 77 4 ----.C.1..%ii -- b FEATURES: l •USDA/PUS Approved •Drop-In nameplate •Shipped assembled •Skid resistant cover 24- Ifill°°°q'tiall •Stainle55 steel t}Ofts1 26•Cast-in floating nut box -Integral drain holes1a• Additional product information e continued on the reverse asps Composites for Infrastructure 2526 Kansas Avenue RtvevsKde Cai tonna 92507 95' 787 0500 Inside Dimensions 951 787 0632 1fa■1 Length Width Depth ,nfoonewoas,s con 33 1/8" 22 1/2" newbasrs con 281/16' 161/2' 21" REV: A 141--60'-0"- PAGE NUMBER CONTACTS: SITE ADDRESS PROJECT NUMBER Construction manager Permit Tech Astound Jeff McConville Phillip Fagin 4 jmcconville@wavebroadband.com pfagin@wavebroadband.com 9640-9552 SW Oak St (503)318-9804 (503)310-5340 Broadband Tigard, OR 97223 100020148 PAGE 4 OF 4 N W A �% E Pedestrian Accommodation,Mid-Block Diagram 5-7 Pedestrian Accommodation Diagrams s The sidewalk should be closed at the nearest intersection on each side of the See Diagrams 5-7 and 5-8.below.for pedestrian accommodations in work work area when a safe.ADA-compliant path through the work area is not zones available. Pedestrian Accommodation Principles: 1 If the work impacts the sidewalk or pedestrian facility,provide a safe. accessible path.where practical.in accordance with the requirements of the ADA ----.1 _._j - 2. If not practical to match the width of the existing pedestrian facilities. It maintain a 4-ft minimum width. 3 Unless a reasonably safe route can be provided through the work dOOMIX'� "°" space,pedestrians should be appropriately directed with advance 00+� 1 °f ;—" 1" signing to cross the road. Do not divert pedestrians into travel lanes. 6102 ( 'Now' sons on 8Mount 4 Install pedestrian closure or detour signing on Type II barricades. Make every practical effort to satisfy the following. . If work closes a sidewalk or sidewalk ramp.close sidewalks at a point where an alternate crossing point or route can be provided. Minimize 7*,eioeK the amount of out-of-direction travel for pedestrians .%� CLOSED • Use a combination of"SIDEWALK CLOSED (R9-9)."SIDEWALK TIP*WI. CLOSED USE OTHER SIDE'(R9-10)."SIDEWALK CLOSED AHEAD (hloin or BOINA CROSS HERE"(R9-11).and"SIDEWALK CLOSED CROSS HERE" RA.va) (R9-11a)signing to direct pedestrians to an alternate facility. • Where there are business destinations between the nearest crosswalk IIII ::- and the work area,close the sidewalk at the business access nearest ildraften0810 the work area.where practical using the SIDEWALK CLOSED sign. i<I`' "°� Or Include the SIDEWALK CLOSED AHEAD CROSS HERE sign at the "�` ONO NM nearest crosswalk prior to the closure. P 11 ,y, , PAGE NUMBER CONTACTS: SITE ADDRESS PROJECT NUMBER Construction manager PermitTech Jeff McConville Phillip Fagin A 7 jmcconville@wavebroadband.com pfagin@wavebroadband.com 9640-9552 SW Oak St (503)318-9804 (503)310-5340 Broadband100020148 Tigard, OR 97223 PAGE 7 OF 7 N /i i� Right Lane Closure,Multi-Lane Non-Freeway Diag.500 5.5 Multi-Lane Roads w `` �� E Right Lane Closure,Multi-Lane Non-Freeway Diag.500 s Diagram 500 covers work which closes the right lane of a multi-lane non- freeway road. If closing more than one lane on a multi-lane road,provide a minimum tangent distance of 2L between the end of the first lane closure taper and the 4 4 t t beginning of the second lane closure taper. f 1 Use truck-mounted flashing warning lights on work and protection • vehicles. See Section 4 3—Lights and Lighted Signs for exceptions. AMA 0031001oAl0 Ow 2. For added visibility,a truck-mounted arrow board or PCMS in caution • mode may be used j 3. When the posted speed is 40 mph or less.the RIGHT LANE CLOSED 1::-." / AHEAD signs may be omitted. ..._,y0 � / 4 Placement of signs in a non traversable median or other median that is not a two-way left turn lane is required for lane closures any time there is room for a truck to be parked on the left,out of the travel lane. t _ Ili* When there no room for a ouon the leftn an additional �i�j�-'�""• 1 � RIGHT LANE CLOSED AHEAD sign should be placed on the right side ,� and placement of signs in the median is optional. • •.r 1113 I 5. if flagging is needed for work vehicle ingress egress.use Flagger • Adak I > • Layout Detail(see Inset). 1. -- — ! I ( Sign Spac nyand Buffer Lengths(feet) —1• --1— i —' i Posted Spdrr•0* s•nO 'ease q�lot ••, SD..d A • C 3rd A 20 SO 2S 100 100 100 75 H. 1 — 41 30 100 • 40 350 330 330 --1�— •s..Note 4 j 1 t — 41$1 S 500 500 NO 210 230 I I t e •• 235 6S� 700 700 700 ` 325 . 70 i i 365 PAGE NUMBER CONTACTS: SITE ADDRESS PROJECT NUMBER Construction manager Permit Tech Astound Jeff McConville Phillip Fagin 4 jmcconville@wavebroadband.com pfagin@wavebroadband.com 9640-9552 SW Oak St (503)318-9804 (503)310-5340 Broadband Tigard, OR 97223 100020148 PAGE 4 OF 4 , N Lane Closure-Near Side of Intersection Diagram 600 5.6 Intersection Operations W �� �i E Lane Closure-Near Side of Intersection Diagram 600 s i Diagram 600 covers closure of an intersection approach lane. Work vehicles may or may not be in the work space. iI Movement of traffic through the intersection is regulated by existing traffic control only. 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 Illm. I., 3 eeds 40 mph or less and for work in place less than 15 minutes. aFor trucksp-mounted arrow panel or PCMS in arrow mode may be used in -___N„\\ _ place of signs shown on the shoulder \\ 4 For speeds over 40 mph and for work in place more than 15 minutes.a • ••• 36'(min.)LANE REDUCTION or LANE CLOSED sign is required inside the merging taper or mounted on the work vehicle. The sign • was milmay be displayed using a truck-mounted PCMS. ^�� 5 Prohibiting left turns will require additional advance warning and regulatory signs. Check with the road jurisdiction before placing -- �._ riNA � regulatory'Left Turn Prohibition"(R3-2)symbol signs. vpm " � `'-'_ Mil DIM The lane closure merging taper shown is required for all speeds and Nam 49 iil • -{ work durations I • Raw 7 Where space allows.install advance warning signs in the median on Y —A multi-lane roads.especially for left lane closures. • Jr j •• I L 8 A"Left Turn Prohibition'(R3-2)symbol sign may be installed on a , ! �(• Type II barricade inside the closure taper. J I 9. When closing an interior lane of a three or more-lane facility,the A • closure taper shall direct traffic into only one of the adjacent lanes,but not both. 40 Si S and lerrlen As reel S bold t^st_M,^..a,.'1000,"1 ] T 75 t0 s.: O 1 12 10r 1a I I00 '' 1I 3@ .. 4 , 4, 140 c - 214 lm 150 ;ns ,. WOAD r tNOFr( a_, j Iw AHEADzm s^e ;o^ I MO HA ss i t ix so . 21s _...as... ,00 rm I no us A le PAGE NUMBER CONTACTS: SITE ADDRESS PROJECT NUMBER Construction manager Permit Tech Astound Jeff McConville Phillip Fagin 4 jmcconville@wavebroadband.com pfagin@wavebroadband.com 9640-9552 SW Oak St (503)318-9804 (503)310-5340 Broadband 100020148 Tigard, OR 97223 PAGE 4 OF 4 City of Tigard •• COMMUNITY DEVELOPMENT DEPARTMEN VOIr L,.g Request for Permit Action io,/ 9 ,cep T I G A R D 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov TO: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner Applicant ❑ Contractor $,. City Staff Check(✓)one REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State/Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): .ffCANCEL/VOID PERMIT APPLICATION. REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). Permit#: WI2OlC 0)25 2 Site Address or Parcel#: ZS + Project Name: WOIit OrlDithAnGt Subdivision Name: Lot#: EXPLANATION: _pc-, v in it n r\QA _ N t h ..- etrA J A Yl GhC_=,i30,21 Signature: el'`' � Date: 81x1 I& Print Name: ,)ors IARefund 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. Route to Sys Admin: Date By Route to Records: Date "VS / 9 By Refund Processed: Date Thai ' Invoice Processed: Date By Permit Canceled: Date /p 9 B Parcel Tag Added: Date By I:\Building\Forms\RegPermitAction_1 15 8.doc P T71VED e14 f r._ I•' 7 u 5 2019 °/'� `' - City of Tigard ,r rIGa,R� PFI#:Z 1 coo 2s� 71ENGINEERING DEPARTNI I �jNING/ENGINEERING TIGARD Public Facilities Improvement (PFI) Permit PROJECT INFORMATION TYPE OF WORK Project name: Washington Square - 100020148 ® TYPE 1-Franchise utility Work performed by»N,PGE, or utility Brief description of project: We will bore a 2 inch conduit between agency greenburg and Washington Square rd. We are setting 2 vaults ❑ TYPE 2-ROW Sidewalk/Driveway/Sewer in the planter strip and entering the existing manhole to access Work performed for the purpose of: the building with the fiber. • Sidewalk installation or repair • Driveway approach installation and repair SITE INFORMATION • Sanitary sewer lateral installation and 9552 SW Oak St Tigard, OR 97223 mamhnetap Location (address if available): 9 ❑ TYPE 3—Full Scale Development Work SE .1- 1 l l ql performed with land use approval which includes any of the following: • Subdivisions or Partitions APPLICANT INFORMATION • Street widening Name: Phillip Fagin • Mainline installation for sanitary sewer, storm sewer, Tigard water, and Tigard Mailing address: 669 Glatt circle water service area City/State: Woodburn OR zip: 97071 ❑ TYPE 4-Small Cell Technology Phone: 503 310 5340 ❑ TYPE 5-Tigard Triangle Email: pfagin@wavebroadband.com Phone: 503 310 5340 NOTE: Type 1 and 2 applications may be Contact name: Phillip Fagin cyn a uilcd to rowpermits tigard-ongov. Phone: 503 310 5340 Email: pfagin@wavebroadband.com CONTRACTOR INFORMATION ❑X Same as applicant Name: CCB Number: 211650 Mailing address: City/State: Zip: Phone: Email: ENGINEER INFORMATION Name: Phillip Fagin Mailing address: 669 Glatt circle City/State: Woodburn OR zip: 97071 Phone: 503 310 5340 Email: pfagin@wavebroadband.com 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 ®No Case number: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-ongov • 503-718-2421 • Page 1 of 4 Ci4 l/aci lelfiatt[.4 3: (o/1 _ wy*sN II4 fD ' ✓Lr_+ , lS feek.►4-, f�.-eL.tt-i-e 4e,.e_g /S to-.N-Ars t4 . C zk/ . 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. Phillip Fagin 8/02/2019 A cant's o thorized agent's signature Print name Date Property owner's signature (if required) Print name Date STAFF USE ONLY Case No:W1 oi1'oO2 Permit fee: Received by: kt- Date: t 151(oi Approved by: Date: Notified by: Date: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 2 of 4 'mti- na+ n P-n - Ti etra(cJunsc _ 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 How many install sites are proposed as part of this permit ❑ Site ddress 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: ❑ 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 O Street Light Plan and Photometric ❑ Engineers seal/signature ❑ Sheet label(project land use name,revision and plan log block,dates and sheet numbers.) O 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 95855 SW Washington Square Rd Asto u n d g q Broadband Tigard, OR 97223 CONSTRUCTION NOTES: 1-ALL WORK AREAS TO BE RESTORED TO LIKE OR BETTER CONDITION. General Location Scope of Work 2-ALL OTHER UTILITIES ARE BASED OFF EXISTING LOCATES OR •'Cl . - ,4.- ;,,,a - -. UTILITY STRUCTURES •; '.c �- � ' - EXISTING CONDUIT = 1,709 3-IT IS THE CONSTRUCTION ` / .d ` ' _' • ' - BORE FOOTAGE = 800 CONTRACTORS RESPONSIBILITY «;L /` y TO CALL FOR LOCATES PRIOR ' `'•: =` SA Washington .oa,u F2. - NEW VAULT = 2 TO DIGGING rr '„ ,�• : \, t s.'� t`leizger �. CONTACTS: ow • .-3 . •' 1'1 ._ H , -- ,. - •�' + Construction Manager- , s• . . , w �•. Jeff McConville .. `� i s I' - - I • r,, _'T jmcconvilje@wavebroadband.com - _�.. (503)318-9804 9804 . " �; ' Permit Tech-Phillip Fagin pfagin@wavebroadband.com t sy ,i j' (503)310-5340 SITE ADDRESS/SECTION: Vicinity Map Legend/Symbology 9640-9552 SW Oak St e .__= ^ ..,..‘• . fir ' ' �\ Tigard, esOR 97223 1 rag — J Packet Description / -, ~+7 ,,, .4 • 1 r, 1, BORE PATH Page 1 MN at` r C . 1 , 1 1g Cover page ��'Ti� - :• t t EXISTING CONDUIT ,/ � Cf �, 2_3 Bore path/Existing conduit _%% . p I 1 1 , In VAULT 4 vault ' = 1 1 • T' -r' - 1 - - eta.. r, I /t i- --4.. -:J ' L. • POLE mow • ` .•.` ^ ri1 ® RISER \, 14 ' . Yw ® wl N " t e - y, PAGE NUMBER PROJECT NUMBER fit ; r -5 1 100020148 r h -,i a —~T=' .R r .� \ i f. ; ' PAGE 1 OF 4 N '+' 10114 w 1 is E The telco vault is located here and we ., ,. I W 1. s will be utilized it to push fiber through i to customer.(1.709') / ---g„Sanitary-� � -. - ' -a. �' ' -.: a� / \ 94 / 1 \ hie iCi iJ \; 1 (17 Cj ��. �840 �aa�'�°stun `r.width ,, f : :T' :. ao:,. 1 w5. / Cc') C9 . J \ 3 (1 \ / / y j \e / f P • \ , 1 oe#611 \) Dig a pit to sweep conduit and bore __ t, . around the corner and head northwest \ o the first set vault.(-24 x 36"). 1 / /r 44 PAGE NUMBER CONTACTS: SITE ADDRESS PROJECT NUMBER Jeff McConville manager PermitliTech Astound Jeff McConville Phillip Fagin 2 jmcconville@wavebroadband.com pfagin@wavebroadband.com 9640-9552 SW Oak St 100020148 (503)318-9804 1503)310-5340 Broadband Tigard, OR 97223 PAGE 2 OF 4 Ni's a til :a _ 3. - N Aloe* ..-- 4 t in'. r I ._ .�... 2_ d.e•ARIE: }� -'fir_ F 1 a J � ♦ .• EaP• �' • fY LLL'. 1. t — t• f. !' + s,J :,= _ v, ``� ` a 0 SI Illik `�1 .� 141 �.* _ !.4 t ,•a+` - .��' Existing Telco vault y _ • `� ` i • Iwo A % ' -I :- 1- . • OW_lig 4 , ,• ■ , . `� \ ' � 1. h. 4 _.a PAGE NUMBER CONTACTS: SITE ADDRESS PROJECT NUMBER Construction manager Permit Tech Astound Jeff McConville Phillip Fagin 3 jmcconville@wavebroadband.com pfagin@wavebroadband com 9640-9552 SW Oak St (503)318-9604 J503)310-5340 Broadband Tigard, OR 97223 100020148 PAGE 3 OF 4 __. .. .-. _. N FCA243624T-00006 , W v4.1 7 E FIBERGLASS/POLYMER CONCRETE ASSEMBLY s 24'x 36'x 24' (For actual dwnenuons see drah+rgiI Fiberglass I Polymer Concrete Assembly, • Tapered "He No Floor.VVU 3.6- "20K."3!8"Hex Bolts.Standard ;AtgilC"'-.-----""P''''''''''''' Nameplate(Specify at time of Orden35 • Installed LOAD RATINGS t I Incidental Traffic-Parking Lot.Sidewalk C•onforms to '�/ ' '''• s / •STMC857 •ANSI/SCTE 77 • FEATURES: Il 411 1111‘.0 `�, •USDA/RUS Approved •Drop-In e eble •Shipped assembled •Stud resistant cover 24• •Stainless steep bolts •Cast-in floating nut box sN• Integral drain holes Additional product information continued on the reverse nemii3 Composites for Infrastructure 2926 Kowa Averse Riverside.Galante 92507 931.797.060C Inside Dimensions 951.7t7.0632 du) Length Width Depth inro®nawbaen corn 33 1M" 22 11t _ neweaacom 281/16- 161/2' 21 REV: A r. PAGE NUMBER CONTACTS: SITE ADDRESS PROJECT NUMBER Construction manager Permit Tech Astound Jeff McConville Phillip Fagin 4 jmcconville@wavebroadband.com pfagin@wavebroadband.com 9640-9552 SW Oak St Tigard, OR 97223 (503)318-9604 (503)310-5340 Broadband 100020148 PAGE 4 OF 4 N w Ii;IS E Pedestrian Accommodation,Mid-Block Diagram 5-7 Pedestrian Accommodation Diagrams s The sidewalk should be closed at the nearest intersection on each side of the See Diagrams 5-7 and 5-8 below for pedestrian accommodations in work work area when a safe.ADA-compliant path through the work area is not zones. available. Pedestrian Accommodation Principles: 1 If the v:ork impacts the sidewalk or pedestrian facility,provide a safe, accessible path;where practical.in accordance with the requirements _ I of the ADA ' 2 If not practical to match the width of the existing pedestrian facilities, maintain a 4-ft minimum width 3 Unless a reasonably safe route can be provided through the work ! I�. ��. "" space,pedestrians should be appropriately directed with advance ,vI ' signing to cross the road. Do not divert pedestrians into travel lanes. 2412 Bonu 4. Install pedestrian closure or detour signing on Type II barricades. 0441 4Make every practical effort to satisfy the following: ! • If work closes a sidewalk or sidewalk ramp,close sidewalks at a point where an alternate crossing point or route can be provided. Minimize VA the amount of out-of-direction travel for pedestrians. •I'A SIDEWALK ,j LIMED • Use a combination of'SIDEWALK CLOSED"(R9-9),"SIDEWALK 2402 T111CLOSED USE OTHER SIDE'(R9-10),"SIDEWALK CLOSED AHEAD SOnun CROSS HERE"(R9-11).and"SIDEWALK CLOSED CROSS HERE" Reip°t 1 (R9-11a)signing to direct pedestrians to an alternate facility. Where there are business destinations between the nearest crosswalk and the work area,close the sidewalk at the business access nearest �� the work area,where practical using the SIDEWALK CLOSED sign. __— s r Include the SIDEWALK CLOSED AHEAD CROSS HERE sign at the CORMIMM mNM nearest crosswalk prior to the closure. 2412 Ztrl� Ward a+604Po DWI. 1 � I I it PAGE NUMBER CONTACTS: SITE ADDRES PROJECT NUMBER Construction manager Permit Tech Astound Jeff McConville Phillip Fagin 7 Jmcconville@wavebroadband.com pfagin@wavebroadband.com 9640-9552 SW Oak St 100020148 (503)318-9804 (503)310-5340 Broadband Tigard, OR 97223 PAGE 7 OF 7 N Right Lane Closure,Multi-Lane Non-Freeway Diag. 500 5.5 Multi-Lane Roads W �`1 E Right Lane Closure,Multi-Lane Non-Freeway Diag.500 s Diagram 500 covers work which closes the right lane of a multi-lane non- freeway road. If closing more than one lane on a multi-lane road,provide a minimum l t t tangent distance of 21 between the end of the first lane closure taper and the beginning of the second lane closure taper. 1_ Use truck-mounted flashing warning lights on work and protection ivehicles. See Section 4.3-Lights and Lighted Signs for exceptions. Alwiem vea3• • sPorn 0Ul 2. For added visibility.a truck-mounted arrow board or PCMS in caution ' mode may be used. I 3 When the posted speed is 40 mph or less.the RIGHT LANE CLOSED 1 AHEAD signs may be omitted. •� 4. Placement of signs in a non traversable median or other median that is • not a two-way left turn lane is required for lane closures any time there ' • '� is room for a truck to be parked on the left,out of the travel lane. • When there is no room for a truck to be parked on the left an additional ri InaaimRIGHT LANE CLOSED AHEAD sign should be placed on the right side and placement of signs In the median is optional. •1< 1E1 © ow • s. If flagging is needed for work vehicle Ingress/egress.use Flagger • Layout Detaa(see Inset). • - Sian Spacin;and Buffer Lengths(feat) Ragrfilli--1- 1 I us .i !peed 4 ■ C spot. • 20 10 50 . ' 25 100 0 100 1 75 tio, 30 I 100 350 350 350 15105 + • • •NINA@4 45• _1a0 SO 500 500 500 no liiI Oa 55 250 0 • as 26 _ f5 700 700 701 32s • TO 345 PAGE NUMBER CONTACTS: ITE ADDRESS Construction manager Permit Tech Astound PROJECT NUMBER Jeff McConville Phillip Fagln 4 jmcconville@wavebroadband.com pfagin@wavebroadband.com 9640-9552 SW Oak St J5031318-saoa (5031310-5340 Broadband Tigard, OR 97223 100020148 PAGE 4 OF 4 N Lane Closure—Near Side of intersection Diagram 600 5.6 Intersection Operations W V.: E Lane Closure—Near Side of Intersection Diagram 600 s Diagram 600 covers closure of an intersection approach lane. Work vehicles may or may not be in the work space. 1 Movement of traffic through the intersection is regulated by existing traffic • control only. 1. Use truck-mounted flashing warning lights on work and protection vehicles. See Section 4.3—Lights and Lighted Signs for exceptions. 4m1. 2 For added visibility.a truck-mounted arrow board or PCMS in caution _ _ mode may be used. ttttt�. 3. For speeds 40 mph or less and for work in place less than 15 minutes. a truck-mounted arrow panel or PCMS In arrow mode may be used In place of signs shown on the shoulder. 4. For speeds over 40 mph and for work In place more than 15 minutes,a • ••• 36'(min.)LANE REDUCTION or LANE CLOSED sign is required M , --- - inside the merging taper or mounted on the work vehicle. The sign • �"°•^y"'�''",'i4 may be displayed using a truck-mounted PCMS. N_1 5. Prohibiting left turns will require additional advance warning and regulatory signs. Check with the road jurisdiction before placing .-------- regulatory'Left Turn Prohibition"(R3-2)symbol signs. Vann Mound 6 The lane closure merging taper shown is required for all speeds and R•.r q =�• work durations. • 7. Where space allows.install advance warning signs in the median on multi-lane roads,especially for left lane closures. • • S. A'Left Turn Prohibition'(R3-2)symbol sign may be installed on a L _41 •• j Type II barricade inside the closure taper. it Oil' 9. When closing an interior lane of a three or more-lane facility,the A closure taper shall direct traffic Into only one of the adjacent lanes.but M !j., not both. 1 m su 7 I a• nIle m n - r- - ra aW0 - rr VYOAr - r- se MIEAD $ no no w UN no V - — in n es PAGE NUMBER CONTACTS: ( � SITE ADDRESS PROJECT NUMBER c manager Permit A s t o u n � I Jeff McConville Phillip Fagin 4 jmcconville@wavebroadband.com pfagin@wavebraadband.com 9640-9552 SW Oak St 100020148 (503)318-9804 f503)310-5340 Broadband Tigard, OR 97223 PAGE 4 OF 4