PFI2014-00131 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
s COMMUNITY DEVELOPMENT Permit#: PF12014-00131
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 12/22/2014
Parcel: SEG800
Jurisdiction:
Site address:
Subdivision: Lot:
Project: Frontier Communications
Project Description: Adjacent to 11783 SW 91st Ave to 11695 SW 91st Ave-Bore 113'from pole 232034 at 11695 SW 91st
AV South then bore 50'west across SW 91st Av and continue on customers property 11783 SW 91st Av
to house. The bore will have a 36"cover, frontier will place 1.25 interdict and fiber for new service.
Owner: FEES
Description Date Amount
PFI Permit Fee 12/18/2014 $300.00
PHONE:
Contractor:
SONICOM
1275 S KOKIAK CIRCLE
CORNELIUS, OR 97113
PHONE: 503-710-2972
FAX:
Applicant:
JOHN COUSINEAU
4155 SW CEDAR HILLS BLVD.
BEAVERTON, OR 97005
PHONE: 503-643-0376
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:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12014-00131
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 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 09-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 10-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 11 -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 12- 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 13- 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 14-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 15-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 16-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 17-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_Utilities 18-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 19-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 20-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 21 -OTHER Applied Notice
(RECEIVED
a City of TigardDEC 16 2014
= Public Facility Improvement CITY OF TIGARD
(PFI) Permit PLANNING/ENGINEERING
General Information: FOR STAFF I ISE ONLY
Property Address/Location(s):11783 SW 91st Av.to 11895 SW gist Av. Engineering ?> �2 oly— C0131
� )-1 i QY# Z,) Case No.:
/J Fee: 3 0-0
ReceiptNo.: 9
*Applicant's Name: Frontier Communications Date: 1 Z 17
Address:4155 SW Cedar Hills Blvd. Application Accepted: ' _LI By--e& W+4i
City/State:Beaverton/OR. Zip: 97005 �Z
Primary Contact: John Cousineau REQUIRED SUBMITTAL
Phone: 503-643-0371 Fax: 503-643-0977 INFORMATION
E-mail: john.cousineauOftr.com Professional Eng'ncered Plans are required
f9
• Street Widening
Contractor's Name: SONIC OM • Subdivision Infrastructure
CCB# 188116 Expiration:.3/24/2016 • Main utility line extension:
Address: 1275 S Kodiak Circle 0 Storm Drain,Sanitary—Tigard
0 v"ater—Tigard eater Service Area
City/State: Cornelius OR Zip:97113 (includes Durham,King City and a
portion of unincorporated Washington
Phone: 503-710-2972 Fax: 503-992-771 County)
**Note:See Engineered Plan
Plans By:John Cousineau _ Submittal Checklist attached.
Address:4155 SW Cedar Hills Blvd For all other work:Submit scaled sketch of the
City/State:Beaverton /OR. Zip: 97005 work to be done.(see attached minimum sketch
Phone: 503-643-0371 Fax: 503-643-0977 requirements and provided sketch area).
Updated:6/24/±913
MCURPI.N\\fasten\fsnd Use Appliatioa<\PuW Faahry
Description of work: Bore 113'from pole 232034 at 11695 RW 91 't fs�mremnu dor`
Av. south then bore 50'west across SW 91st Av. and continue on customers property 11783 SW 91st Av to house.
The bore will have a 36"cover. Frontier will pia -e1 25 interrduct and fiber for now service
Estimated value of work(within the public right-of-way): $3000
Is work related to a LAND-USE DECISION? YES FJ NO Q
If so,please specify(MLP,SDR,SUB,etc.)case#:
Is the work related to a BUILDING PERMIT? YES F] NOFXJ
If so,please specify(BUILDING PERMIT)case#:
City of Tigard 1 13125 SW Nall Blvd.,Tigard,OR 97223 1 503-718-2464 1 waxv.tigard-or.gov I Page 1 of 5
APPLICANTS:
To consider an application complete,you will need to submit ALL of the REQUIRED SUBMITTAL ELEMENTS as described on
the front of this application in the"Required Submittal Elements"box.
NOTE: Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for work.
*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(s)must sign this application in the space provided on the
back of this form or submit a written authorization with this application
(Detailed Submittal Requirement Information sheets can be obtained,upon request,for all types of 1 end Use applications)
BY SIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT:
* The above request does not violate any deed restrictions that may be attached to or imposed upon the subject propem,.
* If the application is grtnted,the applicant will exercise the rights granted in accordance with the terms and subject to all the conditions
and limitations of the approval.
* All of the above statements and the statements in the plot plan,attachments,and exhibits transmitted herewith,are true; and the
applicants so acknowledge that any permit issued,based on this application,may be revoked if it is found that any such statements are
false.
* The applicant has read the entire contents of the application,including the policies and criteria,and understands the requirements for
approving or denying the application.
SIGNATURES of sada owner of the subject property.
DATED this 12th day of December ,2014
John Cousineau -
---Applicant/Authorized Agent's Signature Owner's Signature
Owner's Signature Owner's Signature
City of Tigard 1 13125 SW Hall Blvd.,Tigard,OR 97223 1 503-718-2464 1 \-.,nnv.tigard-or.gov I Page 2 of 5
DEVELOPMENT ENGINEERING FEES
1. Public Facility Improvement(PFI)Permit:
Part 1: AD non-water system improvements
Engineer's estimate X 5%(less$300.00 submittal fee)
Engineer's estimate X 20/6 Plan Review
Part 2: All public water system improvements
Engineer's estimate X 12%
Total Permit Fee=Part 1 +Part 2
PFI Permit Fee Exemptions:
There will be no permit fee charged,or assurance required for the following types of work:
• Sidewalk or driveway repair(less than 20 lineal feet)
• Relocate or replace mailbox
• Ditch cleaning that does not involve regrading.
• Weephole repair
• Curb repair or replacement(less than 20 lineal feet)
• Lawn sprinkler system installation or repair
• Street tree pruning or pl;inting
• Planter strip landscape maintenance
• Test wells
2. Addressing Fee: The fee for this service is$50.00 per address.
SAMPLE
Minimum Sketch Requirements
North Arrow Property Lines&Dimension Slope of Property
Street&Street Name(s) Existing Building,Structures Utility&Street Light Poles
Proposed Work Existing Curb or Edge of Pavement Trees
Existing S/W or D/W Apron Existing Utility Locations(sewer,water,storm)
City of Tigard 1 13125 SW Hall Bh�d.,Tigard,OR 97223 1 503-718-2464 1 w%«v.tigard-or.gov I Page 3 of 5
SAMPLE SKETCH:
Edge of Pavement
I -'*— Ditch
Streetlight I —•—•—•---•— —C—•—
• " Rin Draw.
I I i
T�"I�tatas <f��►srrlttsa-- ,
Existing House
�� I Existing I
Driveway
U
co1
01 I '
v�
I I Existing Shop
i
Powerpole I I I d 1
-----•--7ropertyGne------- -------
I ( f
Fire Hydrant(FH)
I i I
Scale: 'l=30'
I i I
I I I
i i (
i I I
Minimum Sketch Requirements(Put"n/a"if Not Applicable):
North Arrow Property Lines&Dimension Slope of Property
Street&Street Name(s) Existing Building,Structures Utility&Street Light Poles
Proposed Work Existing Curb or Edge of Pavement Trees
Existing S/W or D/W Apron Existing Utility Locations(server,water,storm)
City of Tigard 1 13125 SW Hall Bl d.,Tigard,OR 97223 1 503-718-2464 1 www.tigard-or.gov I Page 4 of 5
GREENBURG RD
11694 ii639 ;�
I 1410 S �-'♦"'' w
11780 : w
>
uz 506 7/0i •_.� a
±,jU.
0
O
.w w
V, Q
1174C 1171#7 w
POLE
232034
TERMINAL
BORE ABOUT 113' 44611
DOWN SW 91 ST AV.
THEN 50' ACROSS T,
ll76 li775 PLACE 1.25 PVC AND M '
FIBER AT A DEPTH OFJ .-
ABOUT 36" �-
w �
1'�(r r r•4
11783 DRIVEWAY
�. rj0'
NO POP
11780
N