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PFI2015-00016 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12015-00016 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 02/19/2015 Parcel: 2S 113B000600 Jurisdiction: Site address: 16580 SW 85TH AVE Subdivision: ROSEWOOD ACRE TRACTS Lot: D Project: NW Natural Project Description: Abandon service regulator and reconnect the service to the main. Possible street cut.WO#3431322 (Rev#1489 1) Owner: FEES Description Date Amount PFI Permit Fee 02/19/2015 $300.00 PHONE: Contractor: PHONE: FAX: Applicant: SHELLY KIRSCHENMAN 220 NW 2ND AVE PORTLAND, OR 97209 PHONE: 503-226-4211 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: Not present Issued By: Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12015-00016 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 Kenny Fisher at 503-816-6146 or email at kenny@tigard-or.gov 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 City of Tigard _ PUBLIC WORKS —ENGINEERING Public Facility Improvement (PFI) Permit TIGARD DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL Check one: N Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS Detailed description: Abandon service regulator and reconnect the N Minor work in right-of-way (sidewalk repair,curb cut,street service to the main. Possible street cut. WO#: 3431322 (Rev# 14891) opening,etc.)requires: •Application form,completed and signed •Submit one(1)copy of scaled sketch Property address/location(s): 16580 SW 85th Ave of the proposed work to be done •Submit one(1)copy of traffic control plan –OR– A OR– Applicant's name: NW Natural / Shelly Kirschenman E) Substantial project work requires PP above items and professional Address: 220 NW 2nd Ave engineered plans for: •Street widening Ci /state: Portland OR Zip: 97209 •Subdivision infrastructure Phone: 503-226-4211 x 4347 Email: smk@nwnatural.com •Main utility line extension: - Storm Drain,Sanitary—Tigard Same N W N - Water—Tigard Water Service Contractor's name: ( ) Area(includes Durham,King City CCB#: Expiration: and a portion of unincorporated Washington County) Address: City/state: Zip: DELIVER APPLICATION TO: City of Tigard Phone: Email: Planning/Engineering 13125 SW Hall Blvd. Andrew Young Engineers name: 9 Tigard,OR 97223 220 NW 2nd Ave \pplicauons for"minor work in right-of-way" Address: only may be emailed to: City/state: Portland OR Lip: 97209 rmmpermits&1i¢ard-or gov Phone: 360-281-6169 Email: andrew.young@nwnatural.com [:OR STAFF NLY USE • Case No.: Estimated value of work (within the public right-of-way): $ Application submittal fee: 3�0 Is work related to a LAND-USE DECISION? ❑ Yes ❑ No Application accepted: If so,please specify (MLP,SDR, SUB,etc.) case #: By: L Date: Is work related to a BUILDING PERMIT? ❑ Yes ❑ No -Application reviewed: If so,please specify(BUILDING PERMIT)case#: By: FS Dare: _Applicant notified: By: !9 Date: 1:\CURPLN\Masters\Land Use Applications Rev.07/16/2014 City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 www.tigard-or.gov • 503-718-2421 0 Page 1 of 4 APPLICANTS 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 or submit a written authorization with this application. BY SIGNING BELOW,THE APPLICANTS) SHALL CERTIFY THAT: • The above request does not violate any deed restrictions that may be attached to or imposed upon the subject proper4. • If the application is granted,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 each owner of the subject property required. e r.�Mnm-.sMiry �—_-- ° _ NG�-"-as"� Shelly Kirschenman 2/18/2015 1u150.�e lT.9S'JO-0900' Applicant/Authorized Agent's signature Print name Date Owner's signature Print name Date Owner's signature Print name Date Owner's signature Print name Date PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-orgov • 503-718-2421 • Page 2 of 4 DEVELOPMENT ENGINEERING FEES 1. Public Facility Improvement(PFI)Permit: Part 1: Required submittal fee$300.00 Part 2: All non-water system improvements Engineer's estimate X 5%(less$300.00 submittal fee) Engineer's estimate X 2%Plan Review Part 3: All public water system improvements Engineer's estimate X 12% Total Permit Fee = Part 2 + Part 3 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 planting • Planter strip landscape maintenance • Test wells PUBLIC FACILITY IMPROVEMENT PERMIT City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2421 Page 3 of 4 SAMPLE SKETCH: sit "� „ St Edge of Pavement I 4— Ditch Streetlight I — ----------- Gm Mew ' a I I ' ' T��rop'o� erTii3�� 1 I II , Existing House 1 I � Existing � I g > Driveway 1 I • 3 I . al I v I I CIA 1 si I 1 O ' I � Existing Shop J � i Powerpole I I� 95' .�. I ----------Froper -Line---- — -- Ir Fire Hydrant(FH) I � I Scale: 'I I I r I I r 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 Trees Existing S/W or of pavement Existing utility locations D/W apron (sewer,water,storm) PUBLIC FACILITY IMPROVEMENT PERMIT Cin-of Tigard - 13125 SW Hall Blvd. - Tigard,Oregon 97223 - www.tigard-or.gov - 503-718-2421 - Page 4 of 4 CROSS SECTIONS GENERAL NOTES N I.Call the following Utilities Notification Canter 80' 48 howl pnor to any'eraawalion: Otcimn 811 m l-800.332-2344 W E Washington.811.1-8('0-424-5555 8' r 1r 17' 7' ep J 2.ATTF'NTION O egos law requires you to follow S pp a rWev adoptnf by the Oregon Utility Notification O i� C fp CD Cane.Thax nils arc ad fonh in OAR 952.OD I E C Q.' W B L C E 0090.You ren obtain otpies of the mks try calling i the anter.(Note.the telephone number Por the Oregon a rY MIN,Notification Center js(503)232-1987 ar 811). 3.Fill out con%o c1 n ikelch as-buill supplied with 04-- ep job packet and mium with work order e r.Only on sa-built is tegmred. 4 All dm.butiea mainsv have a mtnunwn deuh of WIS SW 85TH AVE E/$ 24'and crvices..4 hate a minimum depth of I8- unkas then,is n approval vanence 5 All trmamlmon has must hoe a mimmum depth of b d III 3t1'In Cla,s'I,kxanons and 16'in Claaa 2.3.A 4' k 6 Wtntitrn n d unkm there is n apgwted cananee �ind411� - - dime—a m this—.4—honikdch have pmadaN. mer calm dtmrnamm —f— 7 Pre,wre teal shall be teatef to sonnfance with SW DURHAM RD standar,to CFM.0 F-nglncrnng Stand ni PTad— �. 1l 8 Teat medium fm claa'B'main eha11 be air.unless 4-t?pNr75le 4• 44.V.H othentlac noted.Tm maiium fm cla,s'C•F`mnn shall he was,-I—odierwlz road. 24 12' 9.Fm Clea C or higher test,see Design Document and 4'P 41' N Hydrostat.Report. RECT/9 57' • /�arlalin(It"I �Is,h O W T 11E 4-RELIEF M' aae..r t4aa. sp�r.s D+• 4-was � I f 4'CLMS-O-MAIN W ONLw16-DEEP Class"B" PRESSURE TEST INFORMATION (cWde&label test ares on as -bolt drawing) I Q 2 Test by NNG —Other - •..� er tw. a.. w AAT 3e = 2 ❑ CUT 8 CAP B lH' O ABAN 1-047-021-S-01 C Ico RECONN SVC TO 2"(W)MAIN D 2V rls5a0 E l M2 F I� Order Street Description Plat number lcostinglPipe Si Order lt' 356'.M9 3430744 16580 SW 85th Ata 1-047.021-S-01 1.047.0212019 N/A SM10I IT 3431322 16580 SW 85th Ave ReconnectClass B service to B hftin 1-047-021 Z318 S-0100 SM05 1 —❑ BOND RELOCATE 1-(KI SERVICE AND ABANDON SERVICE REGULATOR 50 100 4S NW Natural O�Feet Engineering Department 1 in=100 ft ADdeEss cm couNrr anTE DE..-ED C4C Dan 01/78/201 18580 SW 85TH AVE TIGARD WASHINGTON OR Daawr( KDC Dan 02109/201 0AnW EN a SW DURHAM RD AwaovEO C4C Dan 02ZIO&o1 aaalE ea/w LDa Dan RECONNECT AFTER ABANDON OF SERVICE REGULATOR Dal' aLaT T ars sac PIPELINE ID- 40/Trn -047-021 T07S ROiW NW 17 RELOCATE/ABAN SVCrM. aeo11cTM"210N. 03431372 00014891 Lane Closure with Flagging FtW vMw LSOM ROAD ArseAo (o�eA B �a 81,nBE � 1 1 SAM O+mrU A o C 108TOP B or IM 100 100 100 100 .. I 38-40 800 860 800 260 Imo'■1/ A 46-M 600 600 600 86p •. \ arraeat�de A � ® ceonr .• • Buffer Tt � � I Tt 1 • I ABE PREPARM ,OSTM A i e �\ YB I �B L- 1 1 � (�� , c LANE Low Volume Single Flagger Option I "CC WOW Diagram No. 320 Two Flagger Operation 63