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PFI2016-00034 n CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT COMMUNITY DEVELOPMENT Permit#: PF12016-00034 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 03/01/2016 Parcel: SEG585 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: PGE Project Description: Adjacent to SW North Dakota St.&SW Greenburg Rd. For sidewalk infill Tigard project. Relocate anchor&down guy. Raising a vault lit to match future grade. Owner: FEES Description Date Amount PFI Permit Fee 03/01/2016 $300.00 PHONE: Contractor: PHONE: FAX: Applicant: TSAHAI ANDERSON 10800 SW AVERY ST TUALATIN, OR 97062 PHONE: 503-672-5466 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 NOT PRESENT Signature: Digitally s,gne,J by kremy Wnson c DN:cnskremy Hansen,wpuN,c Works Department,-u ,ty0 Pgard,email-*myh@tigard ago .US Issued By: L Date 1016030116.-M-OBW Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12016-00034 Type: Condition Name: Status: Severity: PFI_Utilities 02-WORK SITE AREA Not Met 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 Not Met 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 Not Met 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 Not Met 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 Not Met 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 Not Met 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 Not Met 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 Not Met 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 Not Met 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 01 -WORK SITE REQUIREMENTS Not Met 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 11 -TRAFFIC CONTROL MODIFICATION Not Met 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 Not Met 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 Not Met 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 Not Met 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 Not Met 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 Not Met 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 Not Met 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. \Kenny Fisher at 503-816-6146 PFI_Utilities 18-PERMIT/PLAN ON SITE Not Met 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 Not Met 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 Not Met 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 Not Met Notice • RECEIVED City of Tigard FEB 2 9 2016 � GARD PGE WORK ORDER# M1636868 = PUBLIC WORKS —E ��INEERING Public Facility Improvement (PFI) Permit DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL Check one: 8 Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS Detailed description: FOR SIDEWALK INFILL TIGARD PROJECT (] Minor work in right-of-way (sidewalk repair,curb cut,street RELOCATE ANCHOR &DOWN GUY. RAISING A VAULT LIT TO MATCH opening,etc.)requires: FUTURE GRADE •Application form,completed and signed •Submit one(1)copy of scaled sketch Property address/location(s): SW NORTH DAKOTA AND SW of the proposed work to be done GREENBURG RD _: •Submit one(1)copy of traffic control plan S3 S –OR– Applicant's name: TOD SHATTUCK/TSAHAI ANDERSON E) Substantial project work requires PP above items and professional Address: 10800 SW AVERY STREET engineered plans for: TUALATIN, OR 97062 •Street widening City/state: Zip: •Subdivision infrastructure Phone: 503-672-5466 Email: T&DSUPPORTAVERY@PGN.COM •Main utility line extension: - Storm Drain,Sanitary—Tigard - Water—Tigard Water Service Contractor's name: CITY OF TIGARD CONTRACTOR 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. Engineer's name: JANE VAIL Tigard,OR 97223 Applications for"minor work in right-of-way" Address: only may be emailed to: City/state: Zip: ro rmitsngtigard-oLM Phone: 360-852-9158 Email: JANE.VAIL@WALLISENG.NET Case No.: / L� Estimated value of work (within the public right-of-way): $ Application submittal 1�j�, Is work related to a LAND-USE DECISION? ❑ Yes [J No Application accepted:,, If so, please specify (MLP,SDR, SUB,etc.) case #: By: L-C-1. Date: 1� Is work related to a BUILDING PERMIT? ❑ Yes 8 No Applicatio r ed: By: Date: If so,please specify(BUILDING PERMIT)case#: �� l L 2 App. ant notified: 2 Wofk,, /\ o ti 1.4 ' ,��5 &30 ,,t-- 9^wt By Date: J I CURPIN\Mastersland Use Appliratlons Rev.07/16/2014 ok- /b �- 'k. r o City of Tigard 13125 SW Hall Blvd. Tigard,Oregon 97223 • www.tigard-or.gov 50 -718-2421 Page 1 of 4 P �,, -- r APPLICANTS NOTE: Person specified as `Applicant" shall be designated"Permittee"and shall provide financial assurance for work. *When the owner and the applicanf 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 APPLICANT(S) SHALL CERTIFY THAT: • The above request does not violate any deed restrictions that may be attached to or imposed upon the subject property. • 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. Digitally mg-d by TSANAI ANDERSON ////�'�� ////�'�� /��/�'++� TSAHAI ANDERSON -2d1=TSA�1�ERSON@PGNGCOM, US TS�A�bAI AC1dVCSOCI 2/26/16 Dale 2016.02 26 06'51:13-08'00' 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 Cityof 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: sIv ,. -s t Edge of Pavement I -40— Ditch Streetlight — —r—'— a Rain Drain ,� I t r ,•,, 0/ 1 O � I • T—Mro'p'os d'Selw'er'L1R�" N � ►� I ;� Existing House I I �1 I Existing 1 Zr 1 Driveway - 3� a VI 1 CI h I - ;h• ILI a � 1 ml e 1 Tr` 04, V� 1 1 I Existing Shop Powerpole I I� 95,- - - O7ropertyLrne----- -- 1 I I Fire Hydrant(FH) � I I Scale: 1"=30' � I I � I I 1 I I i � 1 MINIMUM SKETCH REQUIREMENTS (Put'IN/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 - www.tigard-or.gov - 503-718-2421 • Page 4 of 4 r --------------------- o y� I 1 CD N a S H Single Flagger Operation Cr for Low Volumes I (Optional) a v, (ADT<400) o I o o cwi 'o > 2 j I BE 01 0 0 0 ; " a e e PREPARED ONE LANE aZ o T" H H H 1� TO STOP AHEAD r' 0 0 o m� m F i-— — '""' •i �_ I ROAD ♦ "T.® ♦ •% WORK o Wi o n> > I K c 9 K 9 K A I--! AHEAD N _ w ro eiav I1� CD 0000� o Om-S , I • A B B C I------------------------i H H 1 mile I n f max. p� 0 U2 K K K K � • B Buffer Protection Vehicle ROAD w/TMA(both Optional) WORK See Chapter 4 _0 AHEAD BE QONE LANE n ROAD PREPARED Two Flagger Operation IN -0AHEAD TO STOP 3 m N m �, (Optional) p OD U, r WR CHECKLIST ANCHORS (� REM YES COMMENT X r Z HOLEDIGGER X Y pX� � BOOM (LEAD) y 4 y W a BACKHOE A A- �S) 6 4 6 uo PGE TRENCH _ Anchof Code Al A3 A5 A7 AS LOCATES X STAKING X Lel FLAGGING X w TREETRIM GUYING LANDSCAPE LL G_ O O O O In LI EASEMENT OS.-LBS. �^" �'" PERMITS X TIGARD 1G1Y G1 G4 G7 GlC G10 GIs GZ2 TRAFFIC PLAIN X CUTSHEET 2GUYS G2 G5 G8 G11,1G20 GZ3 UG CIR.VER. WL 2 VT 12167: 3GUYS G3 G6 G9 G1 G1 G21 TRANSMISSRJN WL 10-PL 5022: 'PGE TO ADD SHUTDOWN 12.00 1'506 VT RISER RING Install CUSTOMER -A5-10'LEAD @ 3,8240 FIR TSHUTDOWN CONTACT SERVICE COORDINATOR SIDEWALK BRACE (OR TRENCH AND CONDUIT INSPECTION PRIOR DOORHANGAR -G17-PRI @ 1,821# F TO BACKFILL.PGE WILL NOT INSTALL WIRE CONTACT WEST @ 2.267# UNTIL TRENCH 151 DO%BACKFILLED -- a SERVICE COORDINATOR COMPANY C11-35C Remove: O 'CURRENT SIDEWALK ANCHOR/BRACE a 503-323.6700 OR 503-46343/18(SALEM) IPH# :;a _- DATE TIME A 167 127 POLE CLASS(1,2,3,4,H1,H2,S) HT-CL VT-12167 POLE HEIGHT 0 ATTENTION: CALL 811 BEFORE YOU DIG 5022 OREGON LAW REQUIRES YOU TO FOLLOW RULES ADOPTED , 40'4 143 40 T A 75 1808 BY THE OREGON UTILITY NOTIFICATION CENTER. 1966 THOSERULES ARE SET FORTH IN OAR 952-001-0010 THROUGH 952-001-0090 YOU MAY OBTAIN COPIES OF THE RULES BY CALLING THE OREGON UTILITY NOTIFICATION CENTER ADMINISTRATION d/(502-232-199 TO REQUEST UTILITY LOCATES CALL THE OREGON K1LaMr rrhet'e�I • UTILITY NOTIFICATION CENTER,811 AT LEAST Call before you 11118 y 1 BUSINESS DAYS PRIOR TO EXCAVATION s SW NORTH DAKOTA S7 9�r .f PGE CONSTRUC770N DRAINING AS-BUILT VERIFICA 71ON8 NESC VIOLATIONS CORRECTED 0 25 50 Fe Foreman Date: PGE General Foreman: Date: SDPM,ENG REVIEW SBUILT SYDESIGNER: GATE SCALE ACCOUM ANO JOB NO Vicinity Map 2/22I2D16 1":25' 1070001 1000004546 M1636668 TITLE w PGE)CITY OF TIGARD CIRCUIT S17f SER RIGHT-OF-WAY PERMIT NOTICE: ` PROGRESS-GREE NBURG 11x17 f- THINK APERMIT FROM THE LOCAL JURISDICTION IS REQUIRED BEFORE ANY FOGE SW NORTH DAKOTA AND SW GREENBURG RG L.AKv$9T P �G1 yWu, WORK IN THE RIGHT-OF-WAY MAYBE PERFORMED. ONLY PGE APPROVEDDESCRIPTION SAFETY CONTRACTORS AND CONTRACTORS WHO HAVE MADE OTHER SPECIAL �? 1 p µ� ADJUST PGE FACILITIES FOR SIDEWALK PROJECT SHEET �'�`4+? •YN1�iy FIRST AGREEMENTS WITH PGE WILL BE ALLOWED TO WORK UNDER PGE'S PERMIT. COUNTY SECTIONS WO K WITH �$�,P THE CONTRACTOR MUST NOTIFY THE LOCAL JURISDICTION 48 HOURS WASHINGTON Cll-35C 10 F 1 ORO F BEFORE WORK IS TO BEGIN. A COPY OF THE PERMIT MUST BE ON SITE. e'ZIRTO.ER DESIGN BY PHONE(503 '_Z BY -�PfiE .ecREwce. TOD SHATTUCK 672-5466 HALEY SI EBERT ►, �. '�� j , 4 '� 6 `; .� ; ��i. •1;, J•. ` { _ 1 'Jam /� j- _ r �� ^ _ ` t ;. . -;_ � „. -� .,, � _ r . �.� - ,, - � �. _ <� N City of Tigard April 28, 2016 PGE Attn: Tsahai Anderson 10800 SW Avery St. Tualatin, OR 97062 Re: Permit No. PFI2016-00034 Dear Applicant: The City of Tigard has processed a refund for fees on the above referenced permit(s) as follows: Site Address: SEG535, North Dakota/Greenburg Project Name: PGE job No.: N/A Refund: ® Check#220678 in the amount of$300.00. ❑ Credit card "return"receipt in the amount of$ Note: Please allow 2-5 days for this refund transaction to be credited to your account by the company that issued your card. ❑ Trust account "deposit" receipt in the amount of$ Comments: Permit fee not required as this work is part of the CIP for sidewalks on 95`h and North Dakota. Refund 100% of application fee. If you have any questions please contact me at 503.718.2430. Sincerely, Z64�A�� Dianna Howse Building Division Services Supervisor Enc. 13125 SW Hall Blvd. a Tigard, Oregon 97223 • 503.639.4171 TTY Relay: 503.684.2772 0 www.tigard-or.gov . " City of Tigard Accela Refund Request This form is used for refund requests of land use, development engineering and building permit application fees. Receipts, documentation and the Request for PermitAction form (if applicable) must be attached to this request form. Refund requests are due to Accela System Administrator by each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts Payable will route refund checks to Accela System Administrator for distribution to applicant. PAYABLE TO: PGE DATE: 3/31/2016 Attn: Tsahai Anderson 10800 SW Avery St REQUESTED BY: Dianna Howse Tualatin, OR 97062 JH TRANSACTION INFORMATION: Receipt#: 402280 Case#: PFI2016-00034 Date: 3/1/2016 Address/Parcel: SEG535 North Dakota/Greenburg Pay Method: CreditCard Project Name: PGE EXPLANATION: Permit fee is not required as this work is part of the CIP for sidewalks on 951h and North Dakota. Refund 100% of application fees. REFUND INFORMATION: Fee Description From Receipt Revenue Account No. Refund Example: Building Permit Fee Example: 2300000-43104 $Amount PFI Permit Fee 100-0000-43114 $300.00 TOTAL REFUND: $300.00 APPROVALS: SIGNATURES/DATE: If under$5,000 Professional Staff If under$12,500 Division Manager If under$25,500 Department Manager If under$50,000 City Manager If over$50,000 Local Contract Review Board FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY Case Refund Processed: Date: 2 /gyp B 1:\Building\Refunds\RefundRequest.doc s 09/01/2010 0 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT w Request for Permit Action 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 • www.tigard-or.gov I'O: CITY OF TIGARD Building Division 13125 SW Hall Blvd.,Tigard,OR 97223 Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff Came;(✓)(InL REFUND OR Name: INVOICE TO: (Businc,sorindividual) oa.. Mailing Address: /0 8'0-a �K-) City/State/Zip: 9 Too. Z Phone No.: 3.(s-?-Z _6-qLLC. PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): ❑ C EL/VOID PERMIT APPLICATION. nRPERMIT FEES (attach copy of original receipt and provide explanation below). INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). ❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit #: PFT ,ZU 1 to — 0 0 3 4 Site Address or Parcel#: �ei, S-3 5-- Z"/^- f SGt) Subdivision Name: / Lot #: EX/P�NATION: ��,,-,n; cc rut 1- cviGk it wo,Wk A 4 o -BG P "At- '4- Signature: Date: Print Name: ZZ Rcfund Policy IV 41;f 1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of: • kny fee which was erroneously paid or collected. • Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort has been expended. • Not more than 80%of the application or permit fee for issued permits prior to any inspection requests. 2. .ill refunds will be returned to the original payer in the form of a check via US postal service. 3. Please allow 3-4 weeks for processing refund requests. FOR OFFICE USE ONL) Route to Sys_admin: Date B Route to Records: Date Refund Processed: Date /(o B Invoice Processed: Date By Permit Canceled: Date /{/ B arcel Tag.-added: I Date B 1:\Building\I-'orrns\ltcgPcrmit.\ction_092314.doc