PFI2020-00169 CITY OF TIGARD
lillCOMMUNITY DEVELOPMENT PUBLIC FACILITIES IMPROVEMENT PERMIT
i , Permit#: PFI2020-00169
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 05/13/2020
Parcel: SEG1172
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Comcast
Project Description: Adjacent to 12570 SW 69th Ave. Rod/rope existing conduit.
Class of Work: FEES
Description Date Amount
Type 1 -Utilities(gas, electric, data) PFI Permit Fee 05/12/2020 $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
PHONE: 5039418656
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: Sff v
ee- et7lk
U
Issued By: TlU/t y \ ie- PIL-�
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PFI2020-00169
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 applicants 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 engineers 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
ill City of Tigard MAY 11 2020 PFI#: 2020-00169
ENGINEERING DEPARTMENTCIN OF TIGARD
�!` It l 1 `��Public Facilitie� r` Gvement (PFI) Permit
PRO ':CT INFORMATION TYPE OF WORK
Projet t name: 335953 Cable-Fiber Plant Extension ® TYPE t_Franchise Utility Work
Brief description of project: Rod/rope existing conduit performed by NWw,POE or utility
ten'
0 TYPE 2—ROW Sidewalk/Driveway/Sewer
Work performed for the purpose of
• Sidewalk installation or repair
sosommos • Driveway approach installation and repair
SITE INFORMATION • Sanitary sewer lateral installation and
12570 SW 69th Ave, Portland, OR 97223 main line tap
l.oca r i m (address if available):
❑ TYPE 3—Fun Scale Development Work
SEG_ 1172 performed with land use approval which
includes any of the following
• Subdivisions or Partitions
APPLICANT INFORMATION • Street widening
Name:
Comcast-Alex Silantiev • Mainline installation for sanitary sewer,
storm sewer, Tigard water, and Tigard
Mailing address: 11308 SW 68th Parkway water service area
City/State: Tigard, OR 9 Zip: 97223 ❑ TYPE 4—Small Cell Technology
Phone:
0 TYPE 5—'Ctgard'I'rianglc
(503) 941-8656
Email: Alexander_Silantiev@comcast.com Phone: (503) 941-8656
NOTE: Type 1 and 2 applications may be
Contact name: Alex Silantiev emailed to rowpermitsaticard4tceov.
Phone: (503) 941-8656 Email: Alexander_Silantiev@comcast.com
CONTRACTOR INFORMATION 0 Same as applicant
Name: Texstar Enterprises LLC ATTN: Scott Boyles CCB Number: 228361
Mailing address: 14122 Arndt Rd City/State: Aurora, OR Zip: 97002
Phone: (503) 793-3140 Email: scottboyles@texstarenterprises.com
ENGINEER INFORMATION
Name: K&B Technical Solutions ATTN: Chad Harbeck
Mailing address: PO Box 2529 City/state: Clackamas, OR zip: 97015
Phone: (503) 650-6041x220 Email: Chad_Harbeck@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 B No Case number:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigatd-or.gov • 503-718-2421 • Page 1 of4
APPLICANTS
NOTE: Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for
work,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.
Chad Harbeck 5/8/2020
Applicant's or authorized agent's signature Print name Date
Property owner's signature (if required) Print name Date
STAFF USE ONLY
Case No:PFI2020-00 1 69 Permit fee: S D. Received by:LS Date: 5/11 20
Approved by: 7.—re* 2'I Date: 6/n/Z0ZD Notified by: Date:501 b
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-orgov • 503-718-2421 • Page 2 of 4
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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
2011 Edition Page 81
Shoulder Work w! Minor Road Encroachment Diag. 300
WORK •
•
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September 2016 Chapter 5
1111
TIGARD
City of Tigard
December 22,2020
K&B Technical Solutions
PO Box 2529
Clackamas, OR 97015
Re: Permit No. PFI2020-00 1 69
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: SEG1172
Project Name: Comcast
Job No.: N/A
Refund Method: ® Check#237559 in the amount of$240.00.
El Credit card "return"receipt in the amount of$ .
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 permit was issued prior to cancellation.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Ornelas
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
ll
1City of Tigard
T IGAR D 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 forPerlin?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 K&B Technical Solutions DATE: 12/9/2020
TO:
PO Box 2529
Clackamas,OR 97015 REQUESTED BY: Dianna Ornelas
TRANSACTION INFORMATION:
Receipt#: 429321 Case#: PFI2020-00169
Date: 5/12/2020 Address/Parcel: SEG1172
Pay Method: CreditCard Project Name: Comcast
EXPLANATION: Per applicant's request as job was cancelled. Refund 80%of permit fees as permit was
issued prior to cancellation.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 23 00000-43 1 04 $Amount
PFI Permit Fee 640-0000-43114 $240.00
TOTAL REFUND: $240.00
APPROVALS: SIGNATURES/DATE:
If under$5,000 Professional Staff _ 7
If under$12,500 Division Manager D. L. Orvl.elcl a
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: r /3 By:
1:\Building\Refunds\RefundRequest.doc x 09/01/2010
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT OCT L 2
CITY C)=�;r-<.
REC
Request for Permit Action suri,o,N
G Dr��l3i0N
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov
TO: CITY OF TIGARD V 0 1
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223 ,Z-//1/Z0 4()
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑■ Applicant ❑ Contractor ❑ City Staff
Check(1)one
REFUND OR Name:
INVOICE TO: (Business or Individual) K&B Technical Solutions
Mailing Address: P.O.Box 2529
City/State/Zip: Clackamas,OR 97015
Phone No.: 719-244-1608
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
0 CANCEL/VOID PERMIT APPLICATION.
0 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#: PFI2020-00169
Site Address or Parcel#: S Ems-// 7
Project Name: CO M e 4-t
Subdivision Name: Lot#:
EXPLANATION: Comcast cancelled their project associated to this permit. Requesting permit to be voided and fee
refunded since no inspections were requested.
Signature: Kyle Browning >='= --••--- - -•• Date: 10/22/2020
Print Name: Kyle Browning
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 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. 30a
yz93./ CC s/,Z.zo ay6•47? •464 6W)'WOO--1/12i/9
FOR OFFICE USE ONLY
Route to Sys Admit': Date By Route to Records: Date 6f-• /y/ ./ By /
Refund Processed: Date/2/ii/2.€1 By O Invoice Processed: Date / By
Permit Canceled: Date/Z/iizj BygD Parcel Tag Added: Date By
I:\Building\Forms\RegPennitAction_l f051 .doc
IIICITY OF TIGARD RECEIPT
I • 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Project Name: Comcast
Site Address: 1G--6Lt ti/__L
Receipt Number: 435840 - 08/13/2021
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12020-00169 $-240.00
Total: $-240.00
PAYMENT METHOD CHECK# AUTH CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Check 237559 DHOWSE 08/13/2021 $-240.00
Payor: K&B Technical Solutions
Total Payments: $-240.00
Balance Due: $240.00
Page 1 of 1
IIIII CITY OF TIGARD RECEIPT
13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TtGARD
Project Name: Comcast
Site Address: d t'C(AfefZ--
Receipt Number: 429321 - 05/12/2020
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
PF12020-00169 PFI 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 6358819 PUBLICUSERO 05/12/2020 $300.00
Payor:
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
3152t08 -�
Shelley Koopman Ste`\ek Cc�vC\.
From: PayGov <no-reply@paygov.us>
Sent: Tuesday, May 12, 2020 2:40 PM
To: Shelley Koopman
Subject: Order Receipt 6358819
ARaiMGQ%,,_US
This email is a confirmation of your Online Payment for PERMIT CENTER
Cardholder Name: Shelley Koopman
Telephone : : (503) 650-6041
Credit Card Type :Visa
Last 4 digits : 4XXX XXXX XXXX 8207
Confirmation Number: 6358819
Card Auth Code : 612104
Transaction ID : 1720088750
Agency Payment Amount : $300.00
Convenience Fee : $9.00
Total Amount Charged : $309.00
First Name:Tremark LLC
Last Name:On Behalf of Comcast
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