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PFI2021-00443 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12021-00443 Date Issued: 12/20/2021 T f c;A g l7 13125 SW Hall Blvd., Tigard OR 97223 503.718.2421 Parcel: SEG357 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: PGE#2927483 Project Description: Replace utility pole 5004; SEG 357 Class of Work: FEES Type 1 -Utilities(gas, electric, data) Description Date Amount PFI Permit Fee 12/17/2021 $300.00 Owner: Total $300.00 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: LAURA REIERSGARD 3700 SE 17TH AVE PORTLAND, OR 97206 PHONE:9713311106 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: ATM etftleCj"(/ Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12021-00443 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 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, <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. Contact Ken Fisher at 503 816 6146 or kenny@tigard-or.gov 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 City of Tigard_ PFI#: 2021-00443 ENGINEERING DEPARTMENT TI t, ,r 1, Public Facilities Improvement (PFI) Permit PROJECT INFORMATION TYPE OF WORK Project name: PGE Job # 2927483 B TYPE 1—Franchise Utility Work Brief description of project: Replace utility pole 5004 performed by NWN,PGE, or utility agency ❑ 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 6805 SW PINE ST main line tap Location (address if available): ❑ TYPE 3—Full Scale Development Work I performed with land use approval which includes any of the following. • Subdivisions or Partitions APPLICANT INFORMATION • Street widening Name: PGE - Laura Reiersgard • Mainline installation for sanitary sewer, Mailing address: 3700 SE 17th Ave storm sewer, Tigard water, and Tigard a City/State: Portland, OR Zip: 72069 0 TYPE 4—Small Cell Technology Phone: 971-331-1106 ❑ TYPE 5—Tigard Triangle Email: laura.m.reiersgard@pgn.com Phone: 971-331-1106 NOTE: Type 1 and 2 applications may be Contact name: emailed to rowpermits(aitigard-or.gov. Phone: Email: CONTRACTOR INFORMATION 0 Same as applicant Name: Black & McDonald; Teagan Wise, PM CCB Number: 155359 Mailing address: 9020 SW Washington Sq Rd, Ste 450 City/State: Tigard, OR Zip: 97223 Phone: 503-457-8639 Email: twise@blackandmcdonald.com ENGINEER INFORMATION Name: Nick Morrow Mailing address: 121 SW Salmon St City/State: Portland, OR Zip: 97204 Phone: 503-983-4867 Email: nicholas.morrow@pgn.com ADDITIONAL INFORMATION Estimated value of workis required(if over$5,000):$ (within the public right-of-way) Is work related to a LAND USE DECISION? EYes 0 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 ofl'igard,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. Laura Reiersgard 12/15/21 Applicant's or authorized agent's signature Print name Date Property owner's signature (if required) Print name Date Case No: PF12021 00443 Permit fee: 31"0: 6a Received by: SPV Date: 12/15/2021 Approved by: t{- vcs 14a-0_ Date: I . .14 - 2.r L Notified by: Pi__ Date: MN)\2o2-1 City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www..tigard-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). 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 0 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 ❑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 • www.tigard-or.gov • 503-718-2421 • Page 3 of 4 9 cn- .. 1- .. S1 Edge of Pavement '�' Ditch Streetlight �•—•�'—•—'—' .t If 1.1 Ae" .j.;:W1 ��•� 17 I I T—prop'osreaarCiine- 1 1.1 'a I Existing House I 'Q ! 1 Existing 1 �, .� Driveway �� oil I 1 i t /i LI iin 1 .,-1 1 d, ' 1 w I o Existing Shop L Powerpole I I o .. e, I 95 ._. I lftope—Iiy--Line—�---- o rA I I Fire Hydrant(FH) I I i I Scale: 1"=30' i I I 1 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 Hall Blvd. • Tigard,Oregon 97223 • wwwtigatd-otgov • 503-718-2421 • Page 4 of 4 1 awW xmui wm.na nn ur wu.._ / .._--`�` OVERHEAD LEGEND ��-T \ an RI MOVE/6 RAN DC)N IA)I I.,r if _INSTALL FACILITIES Os26 10830 ` 1 _INSTALL ADDITIONAL FACILITIES/MOdFY 670 FACILITIES WR CHECKLIST 671 V POLES REM YES COMMENT Kr-al-POLE CIAS511.2,3.4,Nl,H2,S) RJ�f.GEI X ROOM, 6721 R PL 3006 '' POLE HEIGHT MOM X FRAMING- WINCH 105 1 POE! lt01L / 9VL PSDe.� FRAME �/tylL�' St 2 N (� .."�- 010—DISTRIBUTION-LC10710,MU 0010 LOCHS X 5004 CC -- L r '" ; IIPH 2 SGL OE,f91Y1 45'-3 •� PANG X 1 2021 G> , wows X • ,��.-�-`'� h OEM 6805 'NWT ' ` 871. awn d d 6O�4 i a td Li L y d d a�/ PEWITS 6 WM G- k. n ` k \ k TRW MN 6.. (POS.-LBS.) n ^ NILlE1 1 GUY G1 G4 G7 GIG 616 G19 G22 OG RVER < ilk \ \ 2 GUYS 02 65 GB 011 G17 G20 G23 11 ERSSNUIDOMAN c _ 3 GUYS G3 G6 69 G12 G16 G21 G24 CUSTOMER r::7 SMIIDORII 11455 nat 'r -, r ....._______/-- DON!Peat x O CONTACT Pl.50O41 — / _ < COMPANY S Mt U Esri Com nity Maps Contributors,Oregon Metro,State of Oregon GEO,6 (LEAD)(L6S) Anger Code Al A3 AS A7 A8 M2927483 N1 t PL-5004 ATTENRON, CALL 8T1 BEFORE YOU DIG Ell OREGON LAW REQUIRES YOU TO FOLLOW RULES ADOPTED Install: THINK BY ME OREGON UTILITY NOTIFICATION CENTER. POLE, 46'-3 SAFETY THOSE MULES ME SET FORTH IN OAR 932-001-0010 THROUGH CALLING GPO.YOU M4Y OBTAIN COMES OF 010 ME RULES IT BY THE OREGON UTBRY I�� 2021 FIRST! NOTIFICATION CENTER ADMINISTRATION SE (30.1-232-1987) VICINITY MAP Al - L= 15' - 3,340# TO REQUEST UTIUTY LOCATES CALL THE OREGON Know what's below. Al - La 15' - 12,133# UTILITY RUST SS DM0OFRmiE o auv,7inoNT Call before Tou G16 - PRI - 1,493# dig. - ' GIB - PRI - 5,729# PGE DAMAGE/OR DRAWING G16 - NEUT - 1,851# SDPAtENG REVIEW: IASBUILT BY DESIGNER: G16 - NEUT - 6,416# AS-BUILT VERIFICATION & NESC VIOLATIONS CORRECTED - _ -0 Remove', Msd«urneM 1,. ..,,,PN.c-..a m nt,SIR() °u.u<,o° 'o POLE, 40'-4 Foremen: DON. -_._ D10 GE: 11947 a 2. Al DATE: /Q'0)12! SCARP: N/A'ACCOUNT: AMV Ism NO.M2927483 2, G16 Ma 09-2020 OH FITNES REPLACE BIO POLE '.e TREE TNIMM• wLL Lw5064 C° ` WEST PORTLAND-NORTH SIZE E bill O / hntdmmNerequired rt this location PGE/ "'"1OC4AON6775SWPINEST,<Null>,OR,97223 COMMI!NIltATION NOTES ` DESCRIPTIONReplace 40'pole with 45' WI.I PU5004 COUNTY SEC11OW(SI WORN WRH SHUTWILSONVILLE WASHIN6TON C1136A I OP I Communication attached to this pole IRO clew morn DEsjo,,BY PHONE MS) DRAWN RV HMRwRCRgWNRD GfElaRy(Wow 0270)2194605 Diane Wa11449 WILSONVILLE.ON 91070 ®PORTLAND GENERAL ELECTRIC CO.-ALL RIGHTS RESERVED M. Page 94 2011 Edition Self-Regulating Lane Closure Diagram 350 Use this detail for closures of one lane of a low-speed, two-lane, two-way road. 1. Use this diagram only if all of the following are true. a. Work space is less than 200 feet. b. The posted speed is 40 mph or less (unless not posted and speed governed by basic rule). c. Average Daily Traffic (ADT) is less than 400. d. Sight distance (in feet) is more than 750 at each end. 2. Use truck-mounted flashing warning lights on work and protection vehicles. See Section 4.3—Lights and Lighted Signs for exceptions. 3. For added visibility, a truck-mounted arrow panel or PCMS in caution mode may be used. 4. A"Lane Ends (Right)" (W4-2R) symbol sign, or"RIGHT LANE ENDS" (W9-1 R) sign, may be placed inside the cone taper for more emphasis. 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 95 Self-Regulating Lane Closure Diagram 350 WORK • AHEAD • Initial Warning • Sign • A • \ i • ONE LANE , r m (`\\Nir /) ROAD V • Protection Vehicle • ail TO YIELD w/TMA(both Optional) II I� ONCOMING OR TO See Chapter 4 • TRAFFIC ONCOMING TRAFFIC • tBuffir/ le • • 50'-100' • • -•-oRY 1164 A ONE LANE B c.. ROAD /' AHEAD j / , j Ro\ 1 Cy WORK 1 AHEAD / V. Initial i Warning Sign September 2016 Chapter 5