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PFI2020-00429 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT I COMMUNITY DEVELOPMENT Permit#: PF12020-00429 Date Issued: 12/09/2020 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Parcel: 1S127DD01200 Jurisdiction: Tigard Site address: 10031 SW CASCADE AVE Subdivision: None Lot: None Project: PGE Job#M2885264 Project Description: new AT&T small cell installation on pge pole Class of Work: FEES Description Date Amount Type 4 -Small Cell Wireless Facility PFI Permit Fee 12/09/2020 $300.00 Additional Plan Review(minimum charge 12/09/2020 $67.50 Owner: 1/2 hour) Total $367.50 PHONE: REQUIRED INSPECTIONS Call 503-639-4175 for the IVR inspection request line or visit the City of Tigard website at www.tigard-or.aov to schedule inspections online. Contractor: PHONE: Applicant: DENISE CHON 2213 SW BEAVERTON, OR 97003 PHONE: 5034163554 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 PFI2020-00429 Type: Condition Name: Status: Severity: PFI_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 22-DAILY INSPECTION REPORTS Applied Notice Applicant shall submit daily inspection reports, on a weekly basis, to the City's Inspector. PFI_Small Cell 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_Small Cell 24-VALIDATION OF MATERIAUCONSTRUCTION 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_Small Cell 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_Small Cell 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_Small Cell 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_Small Cell 28-AS-BUILT DRAWING Applied Notice 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_Small Cell 31 -OTHER Applied Notice Other City of Tigard PFI #: PF12020 00429 ~IIIII ENGINEERING DEPARTMENT TIGARD Public Facilities Improvement (PFI) Permit PROJECT INFORMATION PGE Job # M2885264 TYPE OF WORK Project name: ® TYPE 1—Franchise Utility Work Brief description of project: AT&T TGARD-002-H NEW SMALL CELL performed by NWN,PGE, or utility agency INSTALLATION_PGE Assist-Priority node, connect non-metered service ❑ TYPE 2—ROW Sidewalk/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): 10031 SW CASCADE AVE main line tap ❑ TYPE 3—Full Scale Development Work performed with land use approval which includes any of the following: • Subdivisions or Partitions APPLICANT INFORMATION • Street widening PGE DENISE CHON FOR Linda Ott • Mainline installation for sanitary sewer, Name: storm sewer, Tigard water, and Tigard 2213 SW 153rd Dr water service area Mailing address: City/State: Beaverton, OR Zip: 97003 X TYPE 4—Small Cell Technology ❑ TYPE 5—Tigard Triangle Phone: CREWCOODINATION-W E STERN@pgn.com Email: Phone: NOTE: Type t and 2 applications may be Contact name: Scott Ziska emailed to rowpermits(aiitigard-orgov. Phone: +1 (503) 416-3554 Email: CONTRACTOR INFORMATION El Same as applicant Name: CCB Number: Mailing address: City/State: Zip: Phone: Email: ENGINEER INFORMATION Name: Mailing address: City/State: Zip: Phone: Email: 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? Oyes El No Case number: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 1 of 4 APPLICANTS NOTE: Person specified as"Applicant" shall be designated"Permittee"and shall provide financial assurance for work,if required by the city pursuant to TMC 15.04.140. * With the exception of a utility operating pursuant to a valid franchise or license with the City of Tigard,when the owner and the applicant are different people,the applicant must be the purchaser of record or a lessee in possession with written authorization from the owner or an agent of the owner. The owner must sign this application in the space provided or submit a written authorization with this application. Franchised or Licensed Utilities are not required to obtain the owner's signature on the application. I, the applicant, certify that: • To the best of my knowledge,all the information provided within this application package is complete and accurate. • The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject property. • If the application is granted,I will exercise the rights granted in accordance with the terms and subject to all the conditions and limitations of the approval. .-4;e1 4L Ott' Linda ott 11.11.20 Applicant's or authorized agent's signature Print name Date Property owner's signature (if required) Print name Date STAFF USE ONLY Case No: PFI2020-00429 Permit fee: 3 6 1 Received by: H Pollard)ate:11/12/2020 Approved by: Y`C-vi t f Date: J i01 Lbze Notified by: f 1/ Date: j2g 2))W City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-ongov • 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 PFI Permit Fee). WATER LINE CONSTRUCTION FEE Part 3: All public water system improvements engineer's estimate X 12%. FOR STAFF USE ONLY FOR STAFF USE ONLY TYPE 4: SMALL WIRELESS FACILITY TYPE 1—3:DETAILED SUBMITTAL CHECKLIST REQUIREMENTS Does applicant have a right-of-way license? ❑Yes ❑No TYPE 1 AND TYPE 2-Must include a sketch showing: Under the wireless facilities standards,is the proposal ❑ Dimensions considered?(check all that apply): 0 Small Cell 0 Macro ❑ Street Name How many install sites are proposed as part of this permit ❑ Site Address application? TYPE 3-Must provide 4 sets of plans (sized 24 x 36 or 22 x 34) and an electronic version of all submittal The proposed equipment is located on which of the following: items. The plans must that include: ❑Public Right-of-Way 0 Private Property ❑ Cover—Site,Vicinity,Abbreviation,Legend If equipment is to be located on private property,describe the ❑ General Notes(City,Water,Sewer,etc.) type&use: ❑ Street(Plan,Profile) ❑ Water,Storm and Sanitary(Plan Profile) ❑ Water Quality Facilities ❑ Grading ❑ Landscaping/Tree Plan ❑ Composite Utility Plan(Electrical,Phone,Gas, Storm, Sanitary,Water,Signage,Street Lights,etc.) ❑ Details ❑ Traffic Sight Distance ❑ Signing and Striping ❑ Street Light Plan and Photometric ❑ Engineers seal/signature ❑ Sheet label(project land use name,revision and plan log block,dates and sheet numbers.) ❑ Engineer's Construction Estimate Additional Submittals (per land use conditions,if applicable) ❑ Traffic Report ❑ Storm water Drainage Calculations ❑ Geotechnical Report ❑ Preliminary Access Report(Sight Distance) ❑ Proposed Plat ❑ Pathway Design ❑ Water Provider Approval City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-orgov • 503-718-2421 • Page 3 of 4 9 ill ' •. Si Edge of Pavement f .— Ditch """""'41° cj Streetlight 4 ./..„ .1 ffl"F'12''Dr"S ITU 47...• I 1/4:ll I i vi •y Existing House 1 d I I• Driveway y Vt , o r t Ci>71 a! I %1 }I al a' A 1• li•P 1 .I U� • ° j Existing Shop 1 cA ca. • Powerpole 1 o i• o 1 ..."-. a -*Pinp6.y Line----.— 1 ;.� (.) I Fire Hyarant(FH) 1 I Scale' 1-=30' i I i I I I TYPE 1 AND TYPE 2: MINIUM SKETCH REQUIREMENTS (Put N/A if not applicable) North arrow Property lines&dimensions Existing utilities locations (sewer, storm,water) Street&street names All existing structures Proposed work Existing curb or edge of pavement Utility&street light poles Existing S/W or D/W apron Slope of property Trees City of Tigard • 13125 SW I Tall Blvd. • Tigard,Oregon 97223 • wwwigardror.gov • 503-718-2421 • Page 4 of 4 M#:M2885264 Job Name:TGARD-002H SW CASCADE AVE WR CHECKLIST Address: 10031 SW Cascade Ave,Tigard,OR 97223 5 �•*=e" = ___ 1RN YES COarENT Pole ID:C1135B-14133 �—— • Assist AT&T with construction of Small Cell site(close proximity to i 1-. L :. • .. DOM OH Primary) ,, .� I 9'--- �'X I 'Of IMP • AT&T to provide all wireless related material .�.,,�-- ---- -- — MATES • Connect non-metered flat rate 120/240V service to Small Cell cabinet . -- % - / n-4 NF x mounted on pole -. _: ,y /' 00NW WESSON • Power on the pole EUDADD Map Thumbnail Aor reR'4 • ''''a'!w-- LAR(nM X aelR IS Olt PH IVICffiCN EIVIDOWN , CUSTOMER E DWI WA OMN - IIVI:IvI MAW RIP CI n0a M Pole Image - ArNNPpN_ CALL BII BEFORE VOLE DIG OREGON LAW REQUIRES YOU TO FOLLOW RULES ADORED THINK EYTMWEGa1 e INNun1N CENNR INCISE ROLES ARE SR1 FORTH FCRTN OM 953-001 Dip ON,•,, SAFETY Two 9sammw r YOU MAY ORAN CONES OF ME RUSES BY CALLING ENE OREGON VIM1IN FIRST! 1.0111VATION CONE ADPAMrsTRMroN O 1502-222-DIES 70 REQUEST Un✓ry LOCATES U.I.I.ME OREGON eiwr••MY MIA- UTILITY NOTIFICATION CENTER,9n AT LEAST (all 2 BUSINESS DAYS PRIOR TO EXCAVATION. Rohm Y•9EIB PGE CONSTRUCTION DRAWING SWMENG REVIEW: IASRUIIT 01 DESIGNER: AS-BUILT VERIFICATION & NESC VIOLATIONS CORRECTED i Ea•man: Dow GE. Dol•:iq an-W1A20 WALE: ,,,,A,,,,AlA[T0MT:1070.V 1 'AMU:1Nx01N1 IMO NO.M]a92N_ \ .,.. AT&T TGARD-002H(Pole C11359-14133) QOAT Overhead Feeder:PROGRESS-SAWYER '@ kp ;PGE/ ou n 10031 SW Cascade Ave,Tigard,OR 97223 Connect non-mal,ed 120240 smoke&assist w/smell sell Cx BEAVERTON Was IInh glen imcnc"m C/13513 �"m's '�' IAn Clew moo 58508 IT NNTI Ixe 6ef$yE 410.9551 (yTn•gpa'M Sketch Details BEAVERTON.OR 9700e OFaTurm GENIAL ELECTRIC CO.-Au scars MUM Aerial view for use with TCP Red pin denotes pole location • k r+. •:. • . tooe a � e i Z4.y www.invarion.com mob / / D/ / 00OT PUNKT* DEVICE SPACING: N 350'+/ en..m / / vice ll..wem uxl awasxl4 TAPER:20' ^ os / o / ......a..e.. `.w"'.: TANGENT:20' �.mh 6/ `"",, K A` `O1 �a"4v ` / e* PG(>µ/ / �..H..� / Ov3H. MAYS VI ..... .,,.,.....wnw 035010 CNden Pacelcaa. ovOa 350'41 / , Pel ELCO INC / / / 1 I //ram\ OvaH' ::: / / 1� / eo . / / 4 �� / 100'+I- /i\`` -i/ 11 -h / / / �- \ �— SW Cascade Ave— • ITIOr • G �n / / 350'+I- b * '\ / ie / ; _ Pole#14133 ROb / / /,4 h 'Zr / / / ; All signs and devices SHALL conform to the MUTCDIOTTCH. • Will adjust to fit field conditions as needed for safety. / / ilk Plan NOT to scale. www.invarion.com T c N Les Schwab Tire Cente Macy s 9 ,� 9 DICK'S Sporting Goods Guitar Center 9 y The Cheesecake Factory V JCPenney C211 7) es, Apple Washington VJashin ° a uare 9 Square SW Washington sy,, 400 110 1 f° Southwest Cascade Avenue . cn n Crescent Grove Cemetery 0)N is of the Sea 9 ° Red Robin Gourmet f!1 . Burgers and Brews `�►` eD r King F. 19ashington Square Rd Panera Bread %s Aye S. -0 S Ai 0 Thirsty Lion Fisherman's [� ors Gastropub and Grill �. Marine & Outdoor T a co Mor Furniture for Less 8 Gustav`s Pub & Gr ODOT PERMIT R zn OWEND MMTINa'e". ascade g PGE(Beaverton LCC) M2835264 n MOM,NUMEIVIOrAl1011: CM/5TM: 10031SW Goode Ave Tigard,OR iFLY- Portland n ravat caeaAcrou 0) CI. Dee et tpllmc,WLIM,MItl-. MALL D Ska t lldu/503.a163SS4 uaarhkappp:.co n J m """"ea" Starbucks Child C Borden Poteko m. rley-Davidson POTELCO INC 47 P Paulson's Floor Coverings SW Shady Ln All signs and devices SHALL conform to the MUTCD/OTTCH. Will adjust to fit field conditions as needed for safety. o;,_,gle plan NOT to scale. Rose City Futsal WEST ici ......J.a ex ...