PFI2015-00092 CITY OF TIGARD RIGHT OF WAY PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12015-00092
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 07/08/2015
Parcel: SEG1919
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: 8605 SW Pinebrook ST
Project Description: Directional drill from the ped, on the South side of SW Pinebrook ST going North 32'across road placing
3/4"pipe with CAN to service 8605 SW Pinebrook ST
Owner: FEES
Description Date Amount
PFI Permit Fee 07/08/2015 S300.00
PHONE:
Contractor:
FISK COMMUNICATIONS CONTRACTING
6307 NE ST. JOHNS RD., STE B
VANCOUVER, WA 98661
PHONE: 360-314-4454
FAX 360-314-4456
Applicant:
RANDY SHIELDS
11308 SW 68TH PARKWAY
TIGARD, OR 97223
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: Not Present
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12015-00092
Tyne: 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 503.816.6146(cell), 503.718.2602(office), or
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
f
1
RECEIVED
Ci and
�o� Tigard JUL 0 6 2015
_ ~ PUBLIC WORKS—ENGINEERING .:.0
Public Facility ImP rovementi�&YTNPtliffi t
DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL
Check one: El Utilities ❑ Sideweik/driveway approach ❑ Street improvements ELEMENTS
Detailed description: Directional drill from the ped, on the SOUTH ❑ Minor wort:in right-of-way
side of SW PINEBROOK ST going NORTH 321 across road placing 3/4" (sideunik repair,curb cut,street
opening,etc)requires:
pipe with CATV to service 8605 SW PINEBROOK ST, 97224. •Application form,completed
and signed
•Submit one(1)copy of scaled sketch
Property address/location(s): 8605 SW PINEBROOK
ST, 97224 of the proposed work to be done
�7! l of!'1/� •Submit one(1)copy of traffic
control plan
1 —OR-
1 Applicanes name: ICAST 111 ❑ Substantial project wosk requires
1 above items and professional
Address: 11308 SW 68TH PKWY engineered plans for:
TIGAR , OR 97223 •Streetwidening
City/state: P•
•Subdivision infrastructure
i Phone: 360.301.1962 Ems, Randy—Shields@cable.comcast.com .Main utility line extension:
- Storm Drain,Sanitan,—Tigard
t - Water—Tigard Water Service
t Contractors name: Fisk Communications Contracting, INC.
Area(includes Durham,King City
t Expiration:
CCB#: ORCCB# 185632 and a portion of unincorporated
2705 NE 65th AVE Washington County)
Address:
City/State: Vancouver, WA Zip: 98661 DELIVER APPLICATION TO:
City of Tigard
Phone:360.314.4454 Fnjail:fcclocates@comcast.net planninglEagng
13125 SW Hall Blvd.
Engineers name: Tigard,OR 97223
Applications for"minor amork iu right-of-:ay"
Address: oiily may be emailed to:
City/state: Zip: rowpermitaCrtltir and-oraov
Phone: Email
Estimated value of work (within the public right-of-way): $±00 00
Case No.: T-1 120 k S
t Application submittal fee:
Is work related to a LAND-USE DECISION? ❑ Yes ® No Application accepted:
If so,please specify (MI P,SDR,SUB,etc)case#: By: . Date:
Application reviewed
1 Is work related to a BUILDING PERMIT? ❑ Yes El No
t
By. Dates
If so,please specify(BUILDING PERMcase#: —"
IT)
� Applicant notified:
t
By. 4_S,_ Date j O J
t.'IannutlRteun4+ee w.aaPk*WM RM 07/JW01d
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.6gard-or.gov • 503-718-2421 • Page 1 of 4
APPLICANTS
NOTE: Person specified as"Apphcant"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 possessiou with wurten
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 applicatiou.
1
► BY SIGNING BELOW,THE APPLICANT(S)SHALL CERTIFY THAT:
• The above request does not violate any deed restrictions that may be attachCd to or imposed upon he-suhjert pmpe ty.
• If the application is granted,the applicant will omrcise 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
t 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.
;;Zant/Aufll�o-V,
ATURES f=Chtf theau 'ect property required.
Athena Logan 7/3/15
' AgisOtore Print name Date
Owners signature Pant name Date
Owners signature Print name Date
t Owner's signature Print name Date
►
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PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2421 Page 2 of 4
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