PFI2014-00047 q CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
x COMMUNITY DEVELOPMENT Permit#: PFI2014-00047
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 08/11/2014
Parcel: SEG784
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Comcast
Project Description: Directional drill from the ped,on the east side of SW Gallo Ave. going west 35'across road placing a
3/4" pipe with CAN to service 11695 SW Gallo Ave. SEG784.
Owner: FEES
Description Date Amount
PFI Permit Fee 08/11/2014 $300.00
PHONE:
Contractor:
FISK COMMUNICATION CONTRACTING INC
2705 NE 65TH AVE.
VANCOUVER, WA 98661
PHONE: 360-314-4454
FAX: 360-314-4456
Applicant:
RANDY SHIELDS
6916 NE 40TH ST.
VANCOUVER, WA 98661
PHONE: 360-301-1962
Total $300.00
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: -'exy
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12014-00047
Type: Condition Name: Status: Severity:
ROW 06-TRAF CTRL-ADVANCE WARNING Continuing Notice
Advance warning of imminent traffic disruption shall be provided to the general motoring public by placement of an advance
notification sign at each end of the construction area 72 hours (min.) before initiation of construction work.
ROW 16-REPAIRS-LIKE MATERIALS REQ Continuing Notice
Property disturbed by construction activity shall be seeded with a standard grass mix; shrubs,flowers, barkdust, existing
signs, pavement markings, mailboxes, etc., shall be reestablished, reinstalled or replaced,with like kind and material.
ROW 19-UTILITY LOCATIONAL CONFLICT Continuing Notice
Contractor 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 permit holders expense. Changes must be approved by the City in advance of work performance. Contractor shall
coordinate the work with affected utility agencies.
ROW 09-TRAF/NOISE CTRL-WORK HRS Continuing Notice
No work will be permitted during the hours of darkness, nor between 9:00 p.m.to 7:00 a.m. Monday through Friday, nor
between 9:00 p.m.to 8:00 a.m. Saturday, nor between 9:00 p.m. to 9:00 a.m. Sunday.
ROW 18-UTILITIES PRELOCATION REQ Continuing Notice
Oregon law requires following the rules adopted by the Oregon Utility Notification Center. Said rules are set forth in OAR
952-001-0010 through OAR 952-001-0080. Copies of the rules may be obtained from the Center by calling (503)232-1987.
If you have questions about the rules,contact the Center. NOTE: Damage to utilities shall be corrected at the permit holders
expense.
ROW 17-DRAINAGE CONTROL REQ Continuing Notice
Effective drainage control is required. Drainage shall be controlled within the work site and shall be so routed that adjacent
private property, public property and the receiving system is not adversely impacted.The City may, at any time, order
corrective action and stoppage of work to accomplish effective drainage control.
ROW 02-PERMIT& PLAN REQ ON SITE Continuing Notice
A copy of the permit and all attachments, and a copy of the approved construction plan and all amendments shall be
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 the aforesaid must be approved by the City, in advance of work performance.
ROW 03-TRAF CTRL-SPECIF (CITY) Continuing Notice
The City's standard specification for traffic control is"Manual on Uniform Traffic Control Devices for Streets and Highways",
U.S. Dept. of Transportation, F.H.A., 1988 Ed.
ROW 07-TRAF CTRL-PRIV PROP ACCESS Continuing Notice
Access to existing properties shall be maintained at all times, including normal delivery service and mail service and if not,
shall be cause for work stoppage until effective access is established.
ROW 04-TRAF CTRL-CONTR RESPON FOR Continuing Notice
Traffic control shall be provided for by the contractor in accordance with the City's standard specification and, also, in
accordance with a City (job specific)approved traffic control plan. A copy of the approved traffic control plan shall be
available at the work area.
ROW 01-CUSTOM CONDITION Continuing Notice
<Custom Condition goes here>
ROW 05-TRAF CTRL-ROAD CLOSURE Continuing Notice
Public roadway shall not be closed to traffic, at any time,without having first obtained written approval from the City
Engineer. The permit holder is responsible for provision of timely notification of traffic flow disruptions to area wide
Emergency Services(Tigard Police Dept.,Tualatin Fire&Rescue)and to Tri-Met and Tigard School District.
ROW 08-TRAF CTRL-DEVICES IN PLACE Continuing Notice
Traffic control devices, flagpersons, etc., shall be in place prior to initiation of construction work and shall be effectively
maintained.
ROW 10-TRAF CTRL-MIN LANE WIDTH Continuing Notice
Minimum travel lane width shall be eleven (11)feet; pedestrian travel shall also be provided for.
ROW 11-TRAF CTRL-CITY CAN MODIFY Continuing Notice
The City reserves the right to add to or modify traffic control requirements as may be necessary to effectively control traffic
and to assure public safety.
ROW 12-INSP 24 HR NOTICE REQUIRED Continuing Notice
The permit holder or his contractor shall notify the City's inspector Kenny Fisher at 503-816-6146 or email at
kenny@tigard-or.gov, twenty-four(24) hours prior to commencing work,twenty-four(24) hours prior to any staged
inspection, and after completing work covered by the permit.
ROW 13-HAZARDS-CERT OF INS Continuing Notice
Maintenance of the work area and approach roads is the responsibility of the permit holder.The work area and approach
roads shall be maintained in a clean condition,free from obstructions and hazards.A copy of the permit holders Certificate
of Insurance shall be available at the work area.
ROW 14-DEBRIS-MATERIALS Continuing Notice
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
cleanup and stoppage of work to accomplish cleanup.
ROW 15-EROSION CTRL REQ Continuing Notice
Effective erosion control is required. Erosion control devices must be installed and maintained meeting D.E.Q.
requirements.The City may at any time order corrective action and stoppage of work to accomplish effective erosion
control.
ROW 20-TRENCH-PATCH/SAFETY/LBILITY Continuing Notice
A temporary hard-surface patch (Cold mix A.C. or Hot mix A.C. base paving) shall be placed on trenches within roadways
at the end of each day's work. No trench, on site or off site, shall be left at any time in an unsafe condition.The permit
holder is responsible for and is liable for hazards or damage resulting from the work.
ROW 21-REPAIRS REQ-INSPTR OPINION Continuing Notice
Work provided for under the permit shall include repair of existing facilities(roads, ditches, etc.)as may be necessary, in the
City Inspectors opinion, to overcome deterioration or damage which occurred in conjunction with the work authorized by the
permit. Corrective work shall be done at the permit holders expense.
ROW 22-AS-BUILT/ENGR CERTIF REQ Continuing Notice
At the end of each year, or an a mutually agreeable yearly date, any entity making changes to its facilities in the public
right-of-way shall submit complete"as-built"drawings 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 engineers certification of installation
compliance(form attached).
ROW 23-DAILY INSP REPORTS REQ Continuing Notice
The permit holders Engineer/Inspector shall submit daily inspection reports, on a weekly basis, to the City's Inspector. (see
Developer-Engineer Agreement note#5).
ROW 24-TESTS/REPTS TO VALIDT CLMS Continuing Notice
The City's Inspector may, at their discretion, require provision of tests and or reports from the permit holder, permit holder's
engineer or contractor to validate claims of material or construction adequacy/compliance. Such tests/reports shall be
provided at the permit holder's expense.
ROW 25-RELEASE-WAIVER REQ Continuing Notice
The permit holder shall provide a copy of a properly executed Release&Waiver document to the City for each ownership
disturbed by construction activity, as evidence of disturbance resolution and owner satisfaction.
ROW 26-MONUMENT PROTECTION REQ Continuing Notice
Existing monuments, property corners, and survey markers shall be protected. Replacement shall be at the permit holders
expense.
ROW 27-PROB SOLVING-RESPON PARTY Continuing Notice
The permit holder shall 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 an
emergency. The permit holder shall notify the City Inspector, in writing, of any/all assignment changes.
ROW 28-CONSTR SAFETY-RESPON PARTY Continuing Notice
The permit holder shall cause his contractor to provide to the City Inspector, in writing,the name and 24 hr emergency
telephone number of a designated"Competent Person"responsible for construction safety as per OR-OSHA, Chap.437,
Div. 3 Construction, Subdivision P- Excavations.The contractor shall notify the City Inspector of any/all assignment
changes.
ROW 29-ESMT/RT OF ENTRY-RESPON Continuing Notice
It is the sole responsibility of the permit holder to provide for 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 permit holder's failure to obtain or provide for proof of right-of-entry or easements.
RECEIVED
City of Tigard AUG 0 4 'e' 114
Application For Work In The I�j ',"EWgy
ROW Permit
Property Address/Location(s): 11695 SW GALLO AVE FOR STAFF USE ONLY
Tigard OR 97223
Case 2c�ly— 8
*Applicant's Name: Comcast Cable
Application Accepted: 5 Bv:
:W(Iress: 6 916 NE 40TH ST
Application Rceicwed:F''t By:�
c:itl�st:ur:
VANCOUVER, WA �;p: 9 8 6 61
Application Fee Due:
Prlm:trr c ornact: Randy Shields
_.�.._...-.�. __.._._._... Applicant Notified:
Mobile 360 301-1962
Randy_Shielas@caiDie.comcast .cable.com Receipt No.:
I.mail:
REQUIRED SUBMITTAL
Contractor's Nam,: Fisk Communication Contracting INC INFORMATION
CCIi# ORCCB# 185632 Fxpiration: ,
• .Application form,completed :incl signed
address: 2705 NE 65th Ave . Submit one (1) copy ot'sca1e(1 ,;kctch of
City stair•: Vancouver WA /ip: 9 8 6 61 the proposed work to lie done
t hone:
360 314-4454 l:ax: 360 314-4456 • Submit otic (1) copy of traffic cl,ntrr,l
1:?mail:
FCCLOCATES@COMCAST.NET plan
Professional I:nt;inccred Plans arc recfuircd
Plans By: for:
WLIress: • Street Widcning
City/state: lip: • Subdivision Infrastructure
Phone: fax:
• \fain utility line extension
l r1Tt117 Rc%.N 21;2111
Descriptionofvvork: Directional drill from the ped, on the EAST side of SW GALLO AVE
going WEST 351 across road placing a 3/411 pipe with CATV to service 11.695 SW
GALLO AVE .
Estimated value of work(within the public right-of-way): $ 6 0 0 . 0 0
Is work related to a LAND-USE DECISION? YES NO a
If so, please specify (ML.P,SDR,SUB,etc.)case#:
Is the-work related to a BUILDING PERMIT? YES N01 "I
If so, please specify (BUILDING PERMIT)case#:
r
Signature of Applicant/Permittee: t=q 4:L Dace: Duly 31st. 201.1
Print Name: MARGARITA VEGA Title:4 DMINISTRATIVE ASSISTANT
Cin°of Tigarcl I 13125 S\X' 1-1x11 lilvd.,'I'igard,(.)It 9'223 I 503-71H-2464 I www.tiptrd-or.gov *��
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Fisk Communications
Contracting Inc.
(364) 314-4454
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