PFI2015-00123 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
• COMMUNITY DEVELOPMENT Permit#: PF12015-00123
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 09/03/2015Parcel: SEG3021
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: NW Natural
Project Description: On Greenfield Drive, north of Benchview Terrace. Install/replace test risers and relief value on a high
pressure district regulator due to maintenance needs. Main on the 5' in ROW Possible street cut.
Owner: FEES
Description Date Amount
PFI Permit Fee 09/03/2015 $300.00
PHONE
Contractor:
PHONE:
FAX:
Applicant:
SHELLY KIRSCHENMAN
220 NW 2ND AVE
PORTLAND, OR 97209
PHONE: 503-2264211
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 PF12015-00123
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
RECEIVED
City of Tigard SEP 01 2015
PUBLIC WORKS—ENGINEERING CITY OF TIGARD
Public Facility Improvement (PeNq�tj�IG/ENGIfyEERING
pern-ut
DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL
Check one: 8 Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS
Detailed description: Install/replace test risers and relief valve on ❑ Minor work in right-of-wap
(sidewalk repair,curb cut,street
a high pressure district regulator due to maintenance needs. Main opening,etc.)requires:
on the 5' in ROW. Possible street cut. •Application form,completed
and signed
•Submit one(1)copy of scaled sketch
Property address/location(s): Greenfield Dr of the proposed work to be done
•Submit one(1)copy of traffic
WO#: 3434031 control plan
–OR–
Substantial project work requires
❑
Applicant's name: NW Natural/Shelly KirSChenman above items and professional
Address: 220 NW 2nd Ave engineered plans for:
•Street widening
Ci /state: Portland OR Gip: 97209 •Subdivision infrastructure
Phone: 603-226-4211 Email: smk@nwnatural.com •Main utility line extension:
- Storm Drain,Sanitary—Tigard
- Water—Tigard Water Service
Contractor's name: Same 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
Applications for"minor work in right-of-way"
Address: only may be emailed to:
City/state: Zip: to rmiteCg7ti�a�td-or,�
Phone: 360-281-6169 Ems: afy@nwnatural.com
Case No.: A
Estimated value of work (within the public right-of-way): $ FF
.Application submittal fee: f300
Is work related to a LAND-USE DECISION? ❑ Yes ❑ No Application accepted:
If so,please specify (MLP,SDR,SUB,etc.) case#: By: - - Date:
Is work related to a BUILDING PERMIT? ❑ Yes ❑ No Apphcatmn reviewed.
If so,please specify(BUILDING PERMIT)case#: By. 9 0 -- Date: 9
At notified:
By: S o Date:
k%CURPUAM+rtersWnd Um Applications Rev.07/01 M
City of Tigard - 13125 SW Hall Blvd. - Tigard,Oregon 97223 - www.dgard-ongov - 503-718-2421 • 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 Lipon the subject o er �
• 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.
NkxcMmun,Sldly
ws a
: �- Shelly Kirschenman 08/28/2015
�� Uee�racn=KxxcMmun.SM/y.
]015 NB 1]20.10-0i90'
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 • www.tigard-or.gov • 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:
SW 91Y " St
Edge of Pavement
Ditch
StreetlightI — —•-----•—•---C---
- a• Rannrtn
1 0
rnI Existing House 1
I I IU
� I Existing 1
Driveway
CI w I ;h•
0
lu 1
3 I .
o
IL
cr,
>
a
V l
> V1 I
oI
i 1 � Existing Shop
C" �
1
Powerpole
I a 95'
Property Line
� I
' I
iI Fire Hydrant(FH)
� � I
Scale: 1"=30'
� 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 Trees
Existing S/W or of pavement Existing utility locations
D/W apron (sewer,water,storm)
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 - wwwtigard-orgov • 503-718-2421 • Page 4 of 4
CROSS SECTIONS GENERAL NOTES N
I.Call the fall-.."Unhua Na,f Icarian CanaA PPR 0 V ED
48 hours F—t .m�Z.Ompm all.x 1-R00~112.2.1µ W E
W.A..glon.RI I arl4WO-424.5555 INSTALL:
2.ATTENTION:Oregon law rcgwel you w folb,e S REG PER STD. BOND
tde.e&rnd I''Ne Oh goo UNI.Nnuficenon
Cema Th.. .,ue act forth m OAR 951-0 01 DWG.F-03-31-0
0090.You mar.6t."--
Meieopm.of the.les Iry calling
the—W(Note.the ld Thnne numha far the Orcgon
IIhh1 Nat.fwat n('enter la l501t 21b1987 or 9I1t
1 Fmom—nownsketchas-budtsupphdoith INSTALL: zr 3
tot,p.ckrl.d rem.-lh work order 0.1%
..h al M rrgmrca RELIEF VALVE PER z
4.All,h.lnhuhm moms m a h.x a.mono.d yah of R7 20C O
2A-.d:n...<m anarrammunumarpth'(IR,
STD.DWG.F-09-46-8 0l la
,nkaa there a Nt aM d ranance. 1+60;
5.All Iransnisaion hoes must ha,c a mtmmum dyrth of x t"vv.t1 i74 � u
10",n Class'1'locations and 16"m CI...2,1.d 1 Q g'NELF"
VARLINCE - hN»tn,ns.,.less there ts.n appnnsd rarmttce Q S 1W
6,A'nttrn Jtmmstons.m this mrol—t—sketch J 6- TE
Iwre precrd—mar scaled Jtmrns.ms W
b>•s,ht 7 pre..ure test shall he teal m acc,.dancr wtlh Ll-
a1—hrd,m CFM and engineering Standard Ptacn" Z SW BENCHVIEW TERR=0+00 BOND
%1 est ma•Jnun I,x clam"H'main shall M an..1— DETAIL R-1
"�'��'f _ othennee nand Teq mrdunn for class'GF"'main 0-044016 ❑ MAINTAIN VALVE
__ shall he,aater.unless aherwls -Ia d
I
MpWA Nw,. sgru.: oMe y Po,Class('or htpho tc'I,sec Destgn Thwart.. 1E0'70FFSET
IhJi„slatia R,p,o r
Class"B" PRESSURE TEST INFORMATION (arae&label test area on as -buil)drawng) 1208*
^
Test by NNG —Other 179'
Tr tF wM 6'RELIEF 179' 1dfi'
rM Dr oR
A — 1a
B
C g N
D
E — — — —
F
w
WELDS
INSTALL
FOOTAGE
42' 6 SIT"IN B API 5L X42 280 RAYED so 57 NOP �TNITYB 013 03 DERS
3403Y
INSTALL 20' 2' W D 8 0.154 opllonal 225 225 225 013 03434031
ABAN 38' 6 517'W e Order Street Description Plat number Coating Pipe Size Type
ABAN S' 2' W D 3433293 Greer"d Or 1-044-016-R-01 1-044016 Z013 WA SM"
3433295 Greenfield Dr 1-044-016-R-01 pressure test 1-041-016 aPPO WA SM09
3434033 Greenfield Or Install 314"(M test risers 1-044-016 2013 S-0075 SM99
SNW Natural ° 50 700
�Feet
Engineering Department 1in=10011 Class"C -F'PRESSURE TEST INFORMATION (arde&Label test area onas -btWtdravAng)
ADDRE.. CRY —.11 STATE DESIGNED C4C DATE 0412912015 Test by NNG —Other
SW GREENFIELD DR TIGARD WASHINGTON OR DRAWN iKDC DAM 0811112015
BETWEEN AND
S W GALLIN CT SW MAPLECREST DR APPROVED C4C DAM p8/151201 A
NAME CREW LDR. DANE B
DISTRICT REG PUTTED DAM C
PUT TwN Rl.o.EC PIPELINE ID- JOB rvrE: -� D -
1-044-016 T02S RDIW SE 4DISTRICT REG
P11 w P PRDJECTntEvstON. E
03434031 201343 F
Legend Notes:
g 1. Maintain ped.access to NORTHWE&TW.inv rion.com
®w.rtuu and through crosswalks NATURAL
c^^• 2. Maintain Min.12'lanes
®
—d—k h..d w2— 3. Maintain local access SERVICE CENTER:
®a 9..9+I.d t..t.9 W20-7b 4. Notify Transit Authority
0 Ra99.rM.ad at least 48 hrs.in
- CONTACT:Richard Pattanon
ti Mgga.yme.l advance of bus stop closure
5. Traffic control plan and all
devices shall comply with
Manifest NOT TO SCALE MUTCD 2009 and OTTCH LOCATION:SW Greenfield Dr
NOTIFY EMS, FIRE 2011 standards Tigard OR
16 x Cone 6. DEVICE SPACING DATE: JOB#
AND POLICE Flag Taper 20' 8126/15 3434031
2 x road work ahead W20-1 All Other Tapers Equal K&D SERVICES
72 HOURS IN AD ANCE
Posted Speed OF OREGON,INC
2 x be prepared to stop W20-7b 1 40'min.Tangent PHONE:503-723-7267
7. 28"Cones FAX:503-7234750
2 x Flagger Ahead I 36"Barrels DRAWN BY:
1 48"Signs wl Flags GARY DOYLE
2 x flagger symbol 8. Cover Stop Signs and/orUuwl TCS#04383
disable lights when at a
1 x controlled Intersection
I 9. Adjust to field conditions
I
w2a
low
1
I
W-71 I PLEASE SCHEDULE
100' WITH DISPATCH
@ 503-723-7287
SW MAPLECREST _ _ — _ — — — — — 4 DAYS IN ADVANCE
AND PROVIDE A
® I COPY OF THE APPROVED
TRAFFIC CONTROL PLAN
w2P7.
CONE SPACING 20'MAX 100'
I
CORNER RADII 10'MAX ti +ll
FLAGGER TAPER= 100'
25
MPH
II
t
100'
SW EE FIRD
DF
` —100-
7h 100'
7100-h100'
TE \
o-2
\
1
f
I
I
I
1
1 Designed By:
KdD Services,as the preparer of this traffic Gary D.Doyle
control plan makes no representation as to its' 1 WATCS#007696
general adequacy or being approved for implementation. ORTCS#04383
Approval must result from the Traffic Engineer or 503-522-9242
other Public Official having statutory enforcement authority
in the jurisdiction.Utilization and implementation of this gdoyle@kndservices.net
plan shall be a result of that approval.
Rel.MUTCD 2009 6A-01(10) r7 TJoy e