PFI2022-00065 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ap tl
: Request for Permit Action
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard or.gm
TO: CITY OF TIGARD
Building Division
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor ET City Staff
(:heck(V)one
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
[' CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
Permit#: PFI 2022 — 000 6 5
Site Address or Parcel#: 11H6 SW arum " a
Project Name: P 6 E Job * M 3d 13 40 4 M3D7 00 6
Subdivision Name: 'ry,-,Ott. C'(, Icm tq - Lot#:
EXPLANATION: 61r�ea�yYr� iS (,�Jc,„J�,,}1 f, fpy] �rv�r Qd� ,
`tot G�.r rsf %r.'?iRl r� 2ri,.✓.
Signature: /� ,, Date: 2. L 8/2022.
Print Name: .T-rt-"i
Refund Police
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• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort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 senice.
3. Please allow 3-4 weeks for processing refund requests.
Route to Sys Admin: Date L Z Z By IS Route to Records: Date By
Refund Processed: Date I By Invoice Processed: Date By
Permit Canceled: Date 1I By Parcel Tag Added: Date By
1:\Building,\Foans\RegPetmitAction_120518.doc
City of Tigard PFI #: 2022-00065
= ENGINEERING DEPARTMENT
. Public Facilities Improvement (PFI) Permit
PROJECT INFORMATION
TYPE OF WORK
PGE Job # M3013467 & M3070045
Project name: 8 TYPE 1—Franchise Utility Work
Brief description of project: PGE to replace pole 12107 and perform performed by NWN,PGF, or utility
agency
overhead work on secondary. PGE to replace pole 6606. Contractor ❑ TYPE2-ROW Sidewalk/Driveway/sewer
to bore and install conduit. PGE to pull wire from 6606 to vault 148. Work performed for the purpose of:
• Sidewalk installation or repair
• Driveway approach installation and repair
SITE INFORMATION • Sanitary sewer lateral installation and
9640 SW Greenbur Rd main line tap
Location (address if available): g
❑ TYPE 3—Full Scale Development Work
Portland, OR 97223 performed with land use approval which
includes any of the following.
• Subdivisions or Partitions
APPLICANT INFORMATION • Street widening
PGE [Submitted by Jeremy Sprague] • Mainline installation for sanitary sewer,
Name: 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:
(503) 672-5446 ❑ TYPE 5—Tigard Triangle
Email.. crewcoordination-western@pgn.com Phone: (503) 464-7777
NOTE: Type 1 and 2 applications may be
Contact name:
Nick Firestone emailed to rowpermits( rigard-ocgov.
Phone: (503) 718-5681 Email: crewcoordination-western@pgn.com
CONTRACTOR INFORMATION ❑ Same as applicant
Name: DJ's Electrical Inc CCB Number: 134732
Mailing address: PO BOX 289 City/State: Brush PrairieNVA Zip: 98606
Phone: (360) 666-1199 Email: office@tradesmenelectric.com
ENGINEER INFORMATION
Name:
Mailing address: City/State: Zip:
Phone: Email:
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? []Yes [E]No Case number:
City of Tigard 13125 SVl%Hall Blvd. • Tigard,Oregon 97223 • www.figard-or.gov 503-718-2421 • Pdge I 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.
QaA-� Jeremy Sprague 02/24/2022
Applic is ora orized agent's signature Print name Date
Property owner's signature (if required) Print name Date
STAFF USE ONLY
Case No: PF12022-00065 Permit fee: Received by: SPV Date: 2/24/2022
Approved by: Date: Notified by: Date:
City of Tigard • 13125 SW Hall Blvd. Tigard,Oregon 97223 www.figa:rd-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 109/6 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 Pemrit Fee).
WATER LINE CONSTRUCTION FEE
Part 3: All public water system improvements engineer's estimate X 12%.
FOR ONLY • ' 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): ❑ 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 Six'Hall Blvd. Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 3 of 4
Sur
Ed a of Pavement
Ditch ---
Streetlight I _._._._._._._ _r_._
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RNn DrJu
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i T �iopos d'Se1werTine-- �
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TYPE I AND TYPE 2:
MINIUM SKETCH
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REQUIREMENTS
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. 0 Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 4 of 4
vA«IMPUI✓.GILT -lsr mit I COMMERCIAL LEGEND
vmw, N NEW PGE FACILITIES TO BE INSTALLED
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1� e RIGHT-OF-WAY PERMIT NOTICE OVERHEAD LEGEND
pn j j A PERMIT FROM THE LOCAL JURISDICTION IS REQUIRED BEFORE ANY
Z WORK IN THE RIGHT-OF-WAY MAYBE PERFORMED. ONLYMMAPPROVED M.EMOVE FACILITI'LS =INSTALL FACILITIES
CONTRACTORS AND CONTRACTORS WHO HAVE MADE OTHER SPECIAL
SyYW4s AGREEMENTS WITH PGE WILL BE ALLOWED TO WORK UNDER FEE'S PERMIT. MODIFY FACILITIES
NrNrrpR SppgRE RO y CONTRACTOR
SB
T BEGIN. JURISDICTIONTIFY THE LOCAL
A COPY OF THE PERMIT MUST BE ON SITE.
CONDUCTORS
PL-12107 --------- INSTALL 142 AL-TX OH SECONDAR`
II--T1I 6651 O POLES
PL- 35'4 SET 20'EAST&12'SOUTH /r�POLE CLASS (1,2.3.4,Ht,H2,S)
( 'M`�-L)--
e ck REMOVE PL 12107 POE OWNED POLE '"OLE HEIGHT (FEET)
PGE OWNED POLE 35'4 PGE TO PULL
5 PGE TO PULL TEMP TRANSFER COMM(S)
❑PGE PULLED.
❑TEMP GE PULEDFER COMM(S) ❑TOPPED TO COMM(S) THINK
? • ❑TOPPED TO COMM(S) TRANSFER SERVICE SAFETY
W 36851 5'4 VICINITY MAP FIRST!
31 1978
Cil-26C 4 C11-MD
R a
12107
354
C1I4rif 1979 Q
6606
45'-3 12107 TRANSFER TEMP SERVICE ',. • rw.aa mn
2006 75�`. 35-4
INSTALLED ON M3013486 O
�,25 _-_ JOB SITE
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&W1 POE CONSTRUCTION DRAWING
sWAaurACT AS—BUILT VERIFICATION & NESC VIOLATIONS CORRECTED
ANY DEVIATION FROM THIS DESIGN MUST This document occvraroy rwrazAnN FIELD Cons
+... -
BE APPROVED BY PGE PROJECT MANAGER Foremen: Dare:
CONTACT SERVICE COORDINATOR DATF 8/812021 SCAUE'NTS JACCOUNT.1070001 JAWOO 1000011118 IJ06NO.M307C045
CONSTRUCTION NOTES: OH FOR mFNCH AND CONDUIT INWEGTION PRIOR TRE
TO SAGKFIUL PGE WILL NOT INSTALL WIRE
UNTIL TRENCH IS IDA%BACKRUJiD. ` Terrace Glen Apartments
1. SEE THE POE ELECTRIC SERVICEREQUIREMENTS (ESR) BOOKFORTHEFIILLSET COO SIZECIRCUIT
OF REQUIREMENTS.THE ESR BOOT(CAN BE FOUND AT httwJ m-n.PaMaMganMl,c 5033-32318 / PROGRESS-GREENBURG srz11x17
2. CUSTOMER IS RESPONSIBLE FOR OBTAINING ALL BUILDING AND ELECTRICAL PERMITS FOR CALL 811 BEFORE YOU DIGR
PGE/ LOCATION
THE APPROPRIATE MUNICIPALITY GUSTOMER IS ALSO RESPONSIBLE FOR OBATINING ALL ATTENTION:
EASEMENTS AND TREE-TRIMMING PERMITS,AS REWIRED. OREGON LAW REWIRES YOU TO FOLLOW RULES ADOPTED ` 9640 SW Greenburg Rd Tigard OR 97223
3. ALL TREE TRIMMING IS REQUIRED TO BE COMPLETED PRIOR TO PGE INSTALLING SERVICE. BY THE OREGON UTILITY NOTIFICATION CENTER. DESCRIPTION
6. CONTACT PGE SERVICE COORDINATOR IN ORDER TO RECEIVE AN APPROVED METER THOSE RULES ARE SET FORTH IN OAR 952-001-0001 (DOR) Relocate PL 12107-Remove PL 6851
SPOT AND CONFIRM THAT THE SERVICE WILL MEET ALL APPLICABLE CODE CLEARANCE THROUGH 952-001-0 100.YOU MAY OBTAIN COPIES OF GOIIrfTV ECTION(51 WORK MTN SHEET
REQUIREMENTS OVER BOUND,STREETS.PARKING LOTS,ROOFS,DECKS AND BALCONIES, THE RULES BY CALLING THE OREGON UTILITY WASHINGTON Cil-26C
ACROSS OR BESIDE OTHER OVERHEAD UTILITY WIRES,AND ADJACENT TO WINDOWS. TIFICATION CENTER ADMINISTRATION Q I SOa•232.196T BEAVERTON 1 OF 1
5. AFTER PASSING THE APPROPRIATE MUNICIPAL ELECTRICAL INSPECTION LINE CREWCENTER DESIGN BY Pilo
CUSTOMER
(SDA DRAWN BY
CUSTOMER TO REQUEST AN INSPECTION BY PGE BY CONTACTING A SERVICE COORDINATOR TO REOVEST UTILITY LOCATES CALL THE OREGON 14101/�IOTI�CM zxll9w�p r�ooe NICK FIRESTONE 71 LIM[ SRAVY NARAYANAN
AT BO 2-8618 OR 503-32Z67001N THE PORTLAND AREA.PGE WILL NOT ENERGIZE UTILITY NOTIFICATION CENTER,811 AT LEAST CdI defer! 4 eEAVEmox
THE SERVICE UNTIL ALL INSPECTIONS HAVE BEEN PERFORMED. 2 BUSINESS DAYS PRIOR TO EXCAVATION. Tw 10 0 PORTLAND GENERAL ELECTRIC CO.-ALL RIGHTS RESERVED
Page 110 2011 Edition
Interior Lane Closure, Multi-Lane Non-Freeway Diag. 510
Diagram 510 covers work which will block the left lane(s) of a multi-lane non-
freeway road.
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. If the adjacent lane in the opposing direction is not closed, cone off the
work space placing the cones in the median or along the centerline if
there is one.
4 Placement of signs in a non traversable median or other median that is
not a two-way left turn lane is required for lane closures any time there
is room for a truck to be parked on the left, out of the travel lane.
When there is no room for a truck to be parked on the left an additional
LEFT LANE CLOSED AHEAD sign should be placed on the right side
and placement of signs in the median is optional.
5. When the posted speed is 40 mph or less, the LEFT LANE CLOSED
AHEAD signs may be omitted.
6. Cones may be placed as shown on centerline in advance of the work
to better gain the attention of motorists.
7. Work vehicle(s) with or without a TMA may be used to protect the
workers and work space.
Sign Spacing and Buffer Lengths Ifeet)
Posted Spacing Between Signs "Buffer"
Speed A B L Space
20 50
25 100 1130 100 75
30 100
35 350 350 350 125
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 111
Interior Lane Closure, Multi-Lane Non-Freeway Diag. 510
ROAD _
WORK
AHEAD
C
t 1 tit
k
LEFT LANE
CLOSED
AHEAD
e
L I :
•o.o_o • Protection Vehicle
w/rMA(troth Optional)
(Optional) Buller, • See Chapter 4
• • Butter
• (Optional)
I • . I L
r Ir
A
* LEFr LANE
CLOSED
•See Note 4 e AHEAD
tit tIt ROAD
C WORK
AHEAD
•r
September 2016 Chapter 6