PFI2020-00478 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, <Trent Brickey>at
<971-228-9269>,to establish a preconstruction meeting.
Please call 503-639-4175,to schedule inspection, use code 738
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
INCity of Tigard PFI#:2020-00478
s ENGINEERING DEPARTMENT
T l(i A RI) Public Facilities Improvement (PFI) Permit
PROJECT INFORMATION
TYPE OF WORK
Project name: WO#: 3634901 P TYPE 1—Franchise Utility Work
Brief description of project: Abandon service to: 9655 SW 74th Ave. Main performed byNWN,PGE, or utility
agency
is on the 10'in ROW at road edge. One 4'x 5'hard surface cut needed. r TYPE 2—ROW Sidewalk/Driveway/Sewer
Work performed for the purpose of:
See attached for details.
• Sidewalk installation or repair
• Driveway approach installation and repair
SITE INFORMATION • Sanitary sewer lateral installation and
Location (address if available):
9655 SW 74th Ave main line tap
r TYPE 3—Full Scale Development Work
SEG3475 performed with land use approval which
includes any of the following:
• Subdivisions or Partitions
APPLICANT INFORMATION • Street widening
Name: NW Natural/Shelly Kirschenman • Mainline installation for sanitary sewer,
storm sewer, Tigard water, and Tigard
Mailing address: 250 SW Taylor St water service area
City/State: Portland OR Zip: 97204 r TYPE 4—Small Cell Technology
r TYPE 5—Tigard Triangle
Phone: 971-979-6054
Email: smk@nwnatural.com Phone: NOTE: Type 1 and 2 applications may be
Contact name: Shelly Kirschenman emailed to rowpermits(t�dgard-or.gov.
Phone: Email:
CONTRACTOR INFORMATION ❑ Same as applicant
Name: Loy Clark/Jade Leedy CCB Number: 52281
Mailing address: PO Box 1369 City/State: Tualatin, OR Zip: 97062
Phone: 971-806-2841 Email: Jade.Leedy@loyclark.com
ENGINEER INFORMATION
Name: Richard Girard
Mailing address: 220 NW 2nd Ave City/State: Portland, OR Zip: 97209
Phone: 360-921-0314 Email: r2g@nwnatural.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? E Yes -No Case number:
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwutigard-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.
4y.Fryu�wp-r.+-.
Auto -- ��..�.,.�.,w Shelly Kirschenman for NW Natural 12/09/2020
Applicant's or authorized agent's signature Print name Date
Property owner's signature (if required) Print name Date
STAFF USE ONLY
Case No: PF12020-00478 Permit fee: ;j00.00 Received by: AL Date: 12/9/2020
Approved by: Yprir`/ • Date: /2 /0/2026 Notified by: 1 p tlDate: 12I1{I20W
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 2 of 4
DEVELOPMENT ENGINEERING FEES
Public Facility Improvement(PFI)Permit:
INITIAL PFI PERMIT FEE
Part 1: Required submittal fee is 10%of the Net PFI Permit Fee.See below for calculations.Minimum of$300.
NET PFI PERMIT FEE
Part 2: All non-water system improvements engineer's estimate X 7%(less the initial PFI Permit Fee).
WATERLINE 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? I Yes No TYPE 1 AND TYPE 2-Must include a sketch
showing:
Under the wireless facilities standards,is the proposal C Dimensions
considered?(check all that apply): I Small Cell Macro r Street Name
How many install sites arc proposed as part of this permit E 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 I Private Property
L Cover—Site,Vicinity,Abbreviation,Legend
L
If equipment is to be located on private property,describe the If Notes(City,Water,Sewer,etc.)
type&use: L Street(Plan,Profile)
C Water,Storm and Sanitary (Plan Profile)
L Water Quality Facilities
L Grading
L Landscaping/Tree Plan
C Composite Utility Plan(Electrical,Phone,Gas, Storm,
Sanitary,Water,Signage,Street Lights,etc.)
C Details
C Traffic Sight Distance
L Signing and Striping
C Street Light Plan and Photometric
I— Engineers seal/signature
r Sheet label(project land use name,revision and plan
log block,dates and sheet numbers.)
C Engineer's Construction Estimate
Additional Submittals
(per land use conditions,if applicable)
C Traffic Report
1- Storm water Drainage Calculations
C Geotechnical Report
L Preliminary Access Report(Sight Distance)
C Proposed Plat
C Pathway Design
C Water Provider Approval
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 3 of 4
4' FII. " \. " F1 I
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MINIUM SKETCH REQUIREMENTS (Put N/A if not applicable)
North arrow Property lines&dimensions Existing utilities locations
(sewer,storm,water)
Street&street names All existing structures
Proposed work Existing curb or edge of pavement Utility&street light poles
Existing S/W or D/W apron Slope of property Trees
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 503-718-2421 • Page 4 of 4
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Lane Closure at Intersection with Flagging Diagram 620
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Page 118 2011 Edition
Lane Closure at Intersection with Flagging Diagram 620
Diagram 620 covers work within an intersection when normal traffic control
must be interrupted. Work vehicles may or may not be in the work space.
1. During flagging, traffic signals shall be turned off. Contact the road
jurisdiction for approval and assistance (see Chapter 3).
2. For multi-lane facilities, traffic approaching the intersection shall be
reduced to a single lane on each approach. See Chapter 3 for
information on flagging through intersections.
3. There should be one flagger for each approach. One flagger may
control two adjacent approaches if sight distance, low volumes on side
roads, and flagger position allows for safe operation and clear direction
to motorists. For low traffic volume intersections (fewer than 400
entering vehicles per day), one flagger may be used.
4. The"ONE LANE ROAD AHEAD" (W20-4) sign is optional and should
be considered on high volume or high speed roads, or when extended
queues may be expected.
Sign Spacing and Buffer Lengths(feet)
Potted Spedne Betw..n Sient "Buffer
Sped A B C Specs
20 50
25 100 100 100 f
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