PFI2021-00037 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
• COMMUNITY DEVELOPMENT Permit#: PFI2021-00037
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 06/08/2021
Parcel: 2S 101 BB01400
Jurisdiction: Tigard
Site address: 12176 SW GARDEN PL
Subdivision: CROW PARK 217 Lot: 2
Project: SQF, LLC
Project Description: New freestanding small cell wireless facility located at 12176 SW Garden PI.
Class of Work: FEES
Type 4-Small Cell Wireless Facility Description Date Amount
PFI Permit Fee 03/02/2021 $300.00
Additional Plan Review(minimum charge 03/02/2021 $270.00
Owner: 1/2 hour)
Total $570.00
PHONE: REQUIRED INSPECTIONS
Call 503-639-4175 for the IVR inspection request line or visit the City of
Contractor: Tigard website atwww.tigard-or.gov to schedule inspections online.
TILSON TECHNOLOGY MANAGEMENT INC
16 MIDDLE ST 4TH FLOOR
PORTLAND, ME 04101
PHONE:2075916427
Applicant:
NICHOLAS BOURNAKEL
16 MIDDLE STREET 4TH FLOOR
PORTLAND, ME 04101
PHONE: 2076710893
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: See application
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12021-00037
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 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—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 ofTigard PFI #: 2-021 -o oo,3 7
ENGINEERING DEPARTMENT
Public Facilities Improvement (PFI) Permit
For use by Utility Providers (Small Cell)
PROJECT INFORMATION TYPE OF WORK
Project name: SQF,LLC—Tigard Small Cell Wireless Facilities
® TYPE 1— Small Cell Technology Nodc
Description of project: See attached Project Description Installation
❑TYPE 4—Utility energization performed
by PGE or utility agency
What utility services will the facilities provision? PERMITTING - APPLICANT SHALL
See attached Project Description
Apply for&obtain PFI Permit.Pay all required
fees.
SITE INFORMATION
Permit will be issued to applicant by City staff and
Location (address if available): 12176 SW Garden PI will expire after 90 days.
�6c—& p70 INSPECTION - CONTRACTOR SHALL
Notify rowpermits @L tigard-or.gov,within 5 days of
APPLICANT INFORMATION (Service Provider) beginning installation.
Name: SQF, LLC Notify rowpennirs( tigerd-or.gov,within 5 days
of completion of installation.
Mailing address: 16 Middle Street,4"Floor
Notify nxvpermits(r7rigard-orgov,5 days before
City/State: Portland, ME 7ip: 04101 connecting or energizing facilities.
Phone: (207)671-0893 Contractor must call 503-639-4175 to schedule
Email: nbournakel@tilsontech.com p (207)671-0893 inspections before 7 a.m.(at the latest)on the day
hone: of inspection.Use code 738
Contact name: Nicholas Bournakel
Phone: (207) 671-0893 Email: nbournakel@tilsontech.com
ROW License Number: 2020-00039
CONTRACTOR INFORMATION ❑ Same as applicant
Name: Tilson Technology Management, Inc. CCB Number: 212930
Mailing address: 16 Middle Street,4th Floor City/State: Portland, ME Zip: 04101
Phone: (207)591-6427 Email: prolicensing@tilsontech.com
City Business License Number: 02519 (This is SQF's business license#.Tilson is an affiliate of SQF.)
ENGINEER INFORMATION
Name: Emad Badiee,Tilson Technology Management, Inc.
Mailing address: 16 Middle Street,4' Floor City/State: Portland, ME zip: 04101
Phone: (404)480-5555 Email: ebadiee@tilsontech.com
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421
1
ADDITIONAL INFORMATION
Estimated value of work:$ $14,500(does not include the cost to run power and does not include any 4G/5G
equipment.
Is work related to a LAND USE DECISION? ❑ Yes ® No I-and Use Case number:
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.
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.
Applicant and Contractor acknowledge receipt of all the City's regulations and TMC and agree to abide by all
regulations contained therein.
Application and Contractor acknowledge receipt and agree to abide by the permitting process and all other City
of Tigard regulations listed on this application.
I hereby certify,on behalf of Applicant, that to the best of my knowledge and belief this information is true and
correct as of the date hereof. Licensee agrees to comply with the provisions in the Tigard Municipal Code,
including,but not limited to Chapter 15.06.
By executing this application,the undersigned affirms that she/he is an authorized representative of the Applicant
with the authority to execute the application and bind applicant to all provisions of the Tigard Municipal Code
r�� C. Nicholas Bournakel 1/22/2021
Applicant's or authorized agent's signature Print name Date
Property owner's signature (if required) Print name Date
STAFF USE ONLY
PFI No: 7-021 - 0&0 3 7 Permit fee: -70 '�� Received by: Date: 1 Z
Approved by: r a Date: (y J 7/Z/ Notified by: Date:�� LILI
City of Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.fgard-or.gov • 503-718-2421
2
DEVELOPMENT ENGINEERING FEES
All Public Facility Improvement(PFI)Permit fees due upfront
INITIAL PFI PERMIT FEE-
Part 1: Required submittal fee is 10%of the Net PFI Pem-iit Fee.See below for calculations.Minimum of$300.
NET PFI PERMIT FEE
Part 2: All non-water system improvements calculated from engineer's estimate x 7%(less the initial PFI Permit Fee).
FOR •
TYPE I PFI: SMALL WIRELESS TYPE 4 PFI:CHECKLIST
FACILITY CHECKLIST
NOTE:Applicant must have a ROW License with Is all applicable small cell equipment installed-
the City of Tigard prior to applying for the PFI (Check box)
❑Yes ❑ No
Does applicant have a right-of-way license? (Check box)
® Yes ❑ No Date of Completion:
ROW License Number: 2020-00039 Contractor must provide photos of the location of the
Small cell installation site from all angles: (N,S,E,W)
Under the wireless facilities standards,is the proposal
considered? (check all that apply)
® Small Cell ❑Macro
How many install sites are proposed as part of this
permit application?
1
The proposed equipment is located on which of the
following: (Check box)
® Public Right-of-Way ❑ Private Property
If equipment is to be located on private property,
describe the type&use:
Who will be using the facilities to provision services?
Wireless cellular companies for siting small cell
antennas.
Will the facilities allow other providers to use
capacity?—Yes
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 www.tigard-or.gov 503-718-2421
3
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TYPE1 AND TYPE 4 PFI
MINIMUM SKETCH
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North arrow REQUIREMENTS 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 • www.tigard-or.gov • 503-718-2421
4
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SITE NAME: SQFCH-CON1003_TIGARD_OR 03 CaN7U"M7N P,PN N,.
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SOUTHWEST GARDEN PLACE
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