PFI2020-00002 y
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1
■
Request for Permit Action 1110e -
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 TigatdBilildingPermits@figard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ,g City Staff
Check(✓)one
REFUND OR Name:
INVOICE TO: (Business or individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAK"CTION FOR THE ITEM(S) CHECKED (✓):
CANVOID PERMIT APPLICATION.
FUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: t F71 W20-00CD2
Site Address or Parcel#: S 5 g
Project Name: T G�
Subdivision Name: Lot#:
EXPLANATION: '�%ktCOtw- o} ?F 120 rf'0Dq-(o4
Signature: Am ks-eL Date: j '&12D
Print Name: yXr G(PCice �—
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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.
FOR OFFICE
Route to S s Admin: Date B Route to Records: Date J / k 7� B
Refund Processed: Date ,#- By,,JW I Invoice Processed: Date B
Permit Canceled: Date J(/ B Parcel TM Added: Date B
1:\Building\Forms\RegPermitAction_1205 8.dm
RECEIVED k/ f
City of Tigard AN U 2 2020 PFI#: UZ' -00002,
ENGINEERING DEPARTMENT CITY OF TIGARD
Public Facilities T iff6% fe"h't (PFI) Permit
PROJECT INFORMATION
PGE Job # M2819204 TYPE OF WORN
Project name: R TYPE 1—Franchise Utility We*
Brief description of project: performed byNWN,PGE, or utility
agency
Replace/Upgrade POLE 6908 to accomodate SVC TO CELL SITE ❑ TYPE 2—ROW Sidewalk/Driveway/Serer
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): �S b main fine rap
10250 SW NORTH DAKOTA ST ❑ TYPE3—with Full landcale Development al Work
performed with land use approval which
includes any of the following.
• Subdivisions or Partitions
APPLICANT INFORMATION • Street widening
Name: PGE LINDA OTT • Mainline installation for sanitary sewer,
storm sewer, 'Tigard water, and Tigard
Mailing address: 2213 SW 153rd DR water service area
City/State: Beaverton, OR Zip: 97003 ❑ TYPE 4—Small Cell Technology-
Phone:
echnologyPhone:
503.612.6093 ❑ TYPE 5—Tigard Triangle
Email: preregcoord@pgn.com phone:
NOTE: Type 1 and 2 applications may be
Contact name:
SEAN ARNOLD emailed to rna�crmiN(n.ri}ard-or.gov.
Phone: 503.672.5479 Email: PREREQCOORD@PGN.COM
CONTRACTOR INFORMATION El Same as applicant
Name: PGE CREW CCB Number:
Mailing address: City/State: 'Lip:
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? ❑Yes [D No Case number:
Cityof Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-ocgov 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 ue not required to obtain the owners 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.
last 0&- LINDA OTT FOR SEAN ARNOLD 12/30/19
Applicant's or authorized agent's signature Print name Date
Property owner's signature (if required) Print name Date
STAFF USE ONLY
Case No: F1UU-060dZ, Permit fee: Received by:--L(L Date:
Approved by: Date: Notified by: Date:
City of Tigard • 13125 SW Hall Blvd • Tigard,Oregon 97223 • www.tigard-orgov • 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).
WATER LINE CONSTRUCTION FEE
Part 3: All public water system improvements engineer's estimate X 12%.
FOR • ONLY
SUBMITTALTYPE 4: SMALL WIRELESS FACILITY TYPE 1-3:DETAILED
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): ❑Small Cell ❑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 ❑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.)
❑ Engineers 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 • www.tigard-or.gov • 503-718-2421 • Page 3 of 4
St
Edge of Pevement
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TYPE I AND TYPE 2:
MINIUM SKETCH REQUIREMENTS (Put N/A if not app] I I
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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 • www..tigaid-or.gov • 503-718-2421 a Page 4 of 4
Page 84 2011 Edition
Stationary Lane Closure with Flagging Diagram 320
Diagram 320 covers total closure of one lane of a two-lane, two-way
roadway. See the detail inset for the layout if using a single flagger to control
both directions of traffic on low volume roads (less than 400 ADT)with good
sight distance as discussed below.
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. Flaggers at each approach are required if any of the following
conditions exist:
a. Night Operations.
b. Work space is over 200 feet in length.
c. Sight distance is less than 750 feet from each approach
through the lane closure.
d. Traffic volumes are greater than 400 ADT,
4. The length between the Flagger Ahead signs shall not exceed one
mile. Use Diagram 340 — Lane Closure with Pilot Car if exceeding one
mile.
5. Cones should be used to outline the work space when curves or other
roadway alignments prevent clear direction for the motorists to pass
the work space safely.
& Cones along the work space are recommended when posted speeds
are 45 mph or greater, when working under heavy traffic or when travel
lanes are narrower than 11 feet.
7. Extended queue signing (see Diagram 5-4) should be used when
traffic queues extend beyond the initial advance warning sign.
8. When flagging near an intersection, the"Flagger Ahead" (CW23-2)
sign should be visible to traffic entering from any side road. Additional
advance warning and Flagger Ahead symbol signs may be placed on
the side road(s).
9. Sign set-up and flagger placement shown may be used for intermittent
full road closures of 20 minutes or less.
10. 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 are expected.
Chapter 5 December 2011
S S g
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(n (P A A W W N N Q •
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ROAD . . w/TMA(both Optional)
<,WORK I7�1■1r See Chapter 4
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RIGHT-OF-WAY PERMIT NOTICE: OVERHEAD LCV C'V D
A PERMIT FROM THE LOCAL JURISDICTION IS REQUIRED BEFORE ANY REMOVE FACILITIES INSTALL FACILITIES
WORK IN THE RIGHT-OF-WAY MAY BE PERFORMED. ONLY PGE APPROVED
elm CONTRACTORS AND CONTRACTORS WHO HAVE MADE OTHER SPECIAL INSTALL ADDITIONAL FACILITIES
AGREEMENTS WITH PGE WILL BE ALLOWED TO WORK UNDER EDE'S PERMIT. /MODIFY FACILITIES
ED-3 THE CONTRACTOR MUST NOTIFY THE LOCAL JURISDICTION 48 HOURS POLES
1551 i+' BEFORE WORK IS TO BEGIN.A COPY OF THE PERMIT MUST BE ON SITE.
CIff3sc �'3' 3Dt9 Hr-cL POLE CLASS (1,2,3,4,Hi,H2,SI
ogD
4V-2 J A 15 uoe5 �— "E HEIGHT (FEETI
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ao'-3 s
1534061 FRAMING
3-'4255T AUC 558 AAC 2D14 '-'-- #d-17-3-- _ C 15 34059 TRANSMISSION d DISTRIBUTION (SEE CODES BELOW
N 4,0AAC 600A D12 FRAMEOISTRIBU-nON-LC1D717 MU0128
SW NORTH DAKOTA ST 1740 (3PH 10"SGL DE FIBERGLAS4,POLY
RC1 BBN2 76
GUYING 32
�.P x O i 0 s 0 6
s i ANCHORS i s Q c POS,-Les.t m m C
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A ( LEAD) y n IN S 7 GUY G1 Gl G7 1 1 1 22
6908 -- PL 69DB .' ( LBS) a `o 2GWS G2 G5 G8 1 1 23
,.�F50'-3 = ANCHOR CODE A7 A3 A5 A7 AB 3 GUYS G3 G8 G9 7 1 2 2l
V•Y 50'-3
68
5554 D1z LINE a VICINITY MAP
9'L
30,204# e1 SW W'd1j.r-,1". SWWnhoakotq S1
G23 PRI 18,582# 55.4 rra
NEUT 11,632# 19K
A 25 3293 1 IlrFnlde mlv
3-142 010 F 40 T B 25 245 1 04' ( JOB SITE
j &LIGHTNING ARRESTER C 25 5 S�
MiIW.Lkee Crane O PA°'
8 Equipment m�
a
Iona 0 r� 110.250 akotaS l
� 1�^,,j NortlT Dakota sleM � rgamvnle
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4..XISITNG 0
e CONDUIT i BeII Tech 6 Supply Inc
TRANSFER EXISTING 30 4"PL CONDUIT UNIT ma F
TO NEW 18'BRKTS 2013 Open
e"
e TRANSFER 30 PRIMARY
REMOVE 4p,
ANY DEVIATION FROM THIS DESIGN MUST
PL 6908 56-4 ,"fig BE APPROVED BY PGE PROJECT MANAGER
FRONTIER OWNED POLE
FRONTIER TO PULL PGE CONSTRUCTION DRAWING
CONSTRUCTION NOTES: OH TEMP TRANSFER COMM(S) CONTACT SERVICE COORDINATORDA'E12,732019 SCALE. NTS 1ACCOUNT 1070001 JAWO: 1000004515 PooNo.M2819204
FOR
PGE PULLED. R TRENCH AND CorvouT INSPECTION PRIOR VAR
BACKFILL.PGE WILL WT INSTALL WRE
1. SEETHE PGE ELECTRIC SERVICE REOUIREMENTS(ESRn BOOK FOR THE FULL SET TOPPED TO COMM(S) MITI TRENCH IS 100%MCKFNIED. AT&T MOBILITY
SERVICE COORDINATOR
OFREQUIREMENTS.
TOM IR IS RES.THE ESR BOOK CAN BE FOUND IL h IG AND DvdsELECTRICAL
PERMITS
/ CIRCUIT SNE
F�0.1323-fi700 OR B00•Ck42.88tB PROGRESS-GREENBURG 11x17
2. CUSTOMER IS RESPONSIBLE FOR OBTAINING ALL BUILDING AND ELECTRICAL FOF
THEAPPROPRIATE MUNICIPALITY CUSTOMER IS ALSO RESPONSIBLE FOR OBATINING ALL CALL 811 BEFORE YOU DIG PGE/ LO Tlo
EASEMENTS AND TREE•TRIMMING PERMITS,AS REQUIRED. ATTENTION
10250 SW NORTH DAKOTA ST BEAVERTON OR
3, ALL TREE TRIMMING IS REQUIRED TO BE COMPLETED PRIOR TO PGE INSTALLING SERVICE. OREGON LAW REQUIRES YOU TO FOLLOW RULES ADOPTED
BY THE OREGON UTILITY NOTIFICATION CENTER. DESCaFTON
4. CONTACT CME ONFIRM
R THAT HE SERVICE
TWILL FETA ALL
AN APPROVED METER THINK THOSE RULES ARE SET FORTH IN OAR 952-01-ODI 0 Reploa and Upgrade PL6908 Io acmmod&. IPH 120240 200A SVC b Ce11Sie
SPOT AND REQUIREMENTSOVERR GOUNE SEREETS PARKING ALL ROOFS BLE CODE CLEARANCEBALCONIES. THROUGH 952-D1-0090.YOU MAY OBTAIN COPIES OF
ACROSS OR BESIDE OTHERMODVERHEAD UTIL ' RES,LOTS
DMA15EW T wwDU OOw°sN1E$� SARBTY THE RULES BY CALLING THE OREGON UTILITY COUNTY IQNIS) wORI WITH $MEET
e ppTr BEAVERTON WASHINGTON ❑135C M2B11076
5. AFTER PASSING THE APPROPRIATE MUNICIPAL ELECTRICAL INSPECTION II-�RQTf NOTIFICATION CENTER ADMINISTRATION (607-232-1980 1 OFI
CUSTOMER TO REQUEST AN INSPECTION BY PGE BY CONTACTING A SERVICE COORDINATOR LINE CREW CENTER �SION aT 72-54 SOJ) MINN BY
ATBD0�5a2- le OR5D3a 7WINTHEPORTLANVAR . GEWRLNOTENERG¢E TO REQUEST UTILITY LOCATES CALL THE OREGON I��rS beloW. a1>Swlsam DR Sean Amald 67T-5479 SuWha Nanrlman
THE SERVICE UNTIL ALL INSPECTIONS HAVE BEEN PERFORMED. UTILITY NOTIFICATION CENTER,811 AT LEAST C0116e10Te OV dig. BFwvEBrax.aaa70m
2 BUSINESS DAYS PRIOR TO EXCAVATION. Y 9- 0 POR7UND GENERIL EIFCTWC CO.-ALL WGNIS RESERVED
r1v MapTitle
Seav� .�._ � f / —
i
7rgar ct City of Tigard. Oregon
f
• �, � CWSVsRelattd Corridor
00Tigard Local WetWrd Invenoryt
0 vo..�e�ana�er.
- lr.dlc'�nvl
FFM41M W Florae
00
Goa;5 Sale Harbor
RUS Slopes Greater tt� 25%
RECEIVED
u,.
JAN 0 2 2020
CITY OF TIGARD
PLANNING/ENGINEERING
`�v7l3SluulYar
Location of hole for new pole
f"s
Location of new anchor
.r
...........
r�.� xl Tly.� ♦J1.
+ _.� n.e...eu.x F•e I•n............nay.....
.atr
4 �O Milaa
. Cty of Tigard
13125 SW Hall Blvd
' Trgord. OR 97223
639-A
01M 2020 (503) ra-or, 11
Otg212020 www,ngard-or_gov
RECEIVED
Samuel Copelan JAN 0 2 9n9n
CITY OF TIGARD
From: Sean Arnold <sean.arnold@pgn.com> PLANNING/ENGINEERING
Sent: Thursday, January 2, 2020 9:24 AM
To: Samuel Copelan; Prereq Coord; ROW Permits
Cc: Olukayode Popoola; Linda Ott
Subject: RE: M2819204 - City of Tigard permit app - 10250 SW NORTH DAKOTA ST
Follow Up Flag: Follow up
Flag Status: Flagged
Caution!This message was sent from outside your organization. Allow sender I Block sender
Hi Sam,
The only work in the ROW will be to open the cut-outs on a pole on North Dakota to turn off the electricity to the pole
being replaced and swap out some fuses. There will be no ground disturbance in the ROW.
Thanks,
Sean Arnold
P / Service and Design Project Manager,BLC
503-672-5479
sean.arnold(r�pgn.com
From:Samuel Copelan<samuelc@tigard-or.gov>
Sent:Thursday,January 2, 2020 9:17 AM
To: Sean Arnold<sean.amold@pgn.com>; Prereq Coord <PreregCoord@pgn.com>; ROW Permits<rowpermits@tigard-
or.gov>
Cc: Olukayode Popoola <Kay.Popoola @ pgn.com>; Linda Ott<Linda.Ott@pgn.com>
Subject: RE: M2819204-City of Tigard permit app- 10250 SW NORTH DAKOTA ST
***Please take care when opening links, attachments or responding to this email as it originated outside of PGE.***
Thank you Sean,
Would you please clarify what work will take place within the ROW?Before Planning routes the PFI request to
Engineering,we have to ensure that a Sensitive Lands Review (SLR) is not required for ground disturbance in
sensitive land areas.
Sincerely,
Sam Copelan
Assistant Planner
1
City of Tigard; Community Development
13125 SW Hall Boulevard
Phone: (503)-718-2450
Email: Samuelc@tigard-or.gov
DISCLAIMER: E-mails sent or received by City of Tigard employees are subject to public record laws. If requested, e-mail
may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law. E-mails are retained
by the City of Tigard in compliance with the Oregon Administrative Rules "City General Records Retention Schedule."
From:Sean Arnold <sean.arnold@pgn.com>
Sent:Thursday,January 2, 2020 8:58 AM
To:Samuel Copelan <samuelc@tigard-or.gov>; Prereq Coord<PreregCoord@pgn.com>; ROW Permits
<rowpermits@tigard-or.gov>
Cc:Olukayode Popoola <Kay.Popoola@pgn.com>; Linda Ott<Linda.Ott(CD pgn.com>
Subject: RE: M2819204-City of Tigard permit app- 10250 SW NORTH DAKOTA ST
Good morning Samuel,
The hole for the new pole will be dug immediately(within a few inches)to the northeast of the existing pole. Less than
1 cubic yard of soil will be removed. The anchor will be driven into the ground 10 feet to the southeast of the new
pole. The work will be done within the parking lot and will not extend into the shaded areas of the map you provided. I
have attached your map with notes regarding the location of ground disturbances. Let me know if you have any
questions.
Thanks,
Sean Arnold
P"/ Service and Design Project Manager,BLC
503-672-5479
sean.arnold n,pan.com
From:Samuel Copelan<samuelc@tigard-or.gov>
Sent:Thursday,January 2, 2020 8:29 AM
To: Prereq Coord<PreregCoord@pgn.com>; ROW Permits<rowpermits @tigard-or.gov>
Cc:Sean Arnold <sean.arnold@pgn.com>; Olukayode Popoola<Kay.Popoola@pgn.com>; Linda Ott
<Linda.Ott@pgn.com>
Subject: RE: M2819204-City of Tigard permit app- 10250 SW NORTH DAKOTA ST
***Please take care when opening links, attachments or responding to this email as it originated outside of PGE.***
Good morning,
The proposed work will take place within several sensitive land areas; therefore,we will need more information on
the proposed work. Please answer the following:
• Will there be any ground disturbance?
2
o If so, hour many cubic yards of soil will be removed?
• Will the proposed work take place completely within paved area?
In addition, please indicate where work will take place on the attached site plan.
Thanks,
Sam Copelan
Assistant Planner
City of Tigard; Community Development
13125 SW Hall Boulevard
Phone: (503)-718-2450
Email: Samuels dtigard-ongov
DISCLAIMER: E-mails sent or received by City of Tigard employees are subject to public record laws. If requested, e-mail
may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law. E-mails are retained
by the City of Tigard in compliance with the Oregon Administrative Rules "City General Records Retention Schedule."
From: Prereq Coord <PreregCoord@pgn.com>
Sent:Thursday,January 2,2020 7:09 AM
To: ROW Permits<rowpe rm its @tiga rd-or.gov>; Prereq Coord <PreregCoord@pgn.com>
Cc:Sean Arnold <sean.amold @pgn.com>; Olukayode Popoola<Kay.Popoola@pgn.com>; Linda Ott
<Linda.Ott@pgn.com>
Subject: M2819204 -City of Tigard permit app-10250 SW NORTH DAKOTA ST
Good morning CITY OF TIGARD PERMIT TEAM,
Attached is the CITY OF TIGARD Permit Application, Sketch and TCP for PGE JOB M2819204.
Please contact Sean Arnold at 503.672.5479 with any questions.
Thank you for all that you do,
Linda Ott
Linda Ott —Linda.ott( .pgn.com
Line Design Crew Coordination—Western Permit Coordinator--Administrative Assistant
2213 SW 153''Beaverton,OR 97003—503.612.6093
PortlandGeneral.com• Follow us on social @PortlandGeneral
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