PFI2016-00042 ® CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12016-00042
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 03/07/2016
Parcel: SEG674
Jurisdiction: Tigard
Site address: 11500 SW 90
Subdivision: Lot:
Project: Frontier PFI
Project Description: A 17' bore parallel to SW 90th ave along the frontage of 11495 to the north property line. Then continue
cross to 11500 to SW 90th ave. This is to place a 1.25"conduit and fiber.
Owner: FEES
Description Date Amount
PFI Permit Fee 03/07/2016 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
JOHN COUSINEAU
4155 SW CEDAR HILLS BLVD
BEAVERTON
PHONE: 503-643-0371
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 PF12016-00042
Type: Condition Name: Status: Severity:
PFI_Utilities 04-WORK SITE REPAIRS 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 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 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 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 06-TRAFFIC CONTROL PLAN 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 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 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 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 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 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 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 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 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 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 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
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 @ 503-816-6146
PFI_Utilities 18-PERMIT/PLAN ON SITE 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 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 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 Notice
RECEIVED
MAR O 1 2016
City of Tigard CITY OF TIGARD
° PUBLIC WORKS —ENGINEERING PLANNING/ENGINEERii'l
Public Facility Improvement (PFI) Permit
DESCRIPTION OF WORK(in the right-of-way) REQUIRED SUBMITTAL
Check one: ® Utilities ❑ Sidewalk/driveway approach ❑ Street improvements ELEMENTS
Detailed description: A 17' bore parallel to SW 90th Ave along the El Minor work in zight-of-way
(sidewalk repair,curb cut,street
frontage of 11495 to the north property line. Then continue cross opening,etc.)requires:
to 11500 to SW 90th Ave. This is to place a 1.25" conduit and fiber •Application form,completedand signed
•Submit one(1)copy of scaled sketch
Property address/location(s): 11500 SW 90th Ave. where customer of the proposed work to be done
•Submit one(1)copy of traffic
is requesting service. It's just north of SW Lomita Ave. control plan
G-1 -OR-
❑ Substantial project work requires
Applicants name: Frontier Communications /Cousineau above items and professional
Address: 4155 SW Cedar Hills Blvd, engineered plans for:
'SwideningCity/state: Beaverton Zip: 9700 Subdiviion
infrastructure
Phone: 503-643-0371 Email: john.cousineauafir.com •Main utility line extension:
Storm Drain,Sanitary—Tigard
Water—Tigard Water Service
Contractor's name: Sonlcom Area(includes Durham,King City
CCB#: 188116 Expiration: 3124016 and a portion of unincorporated
Address: 1275 S Kodiak Circle Washington County)
City/state: Cornelius Zip: 97113 DELIVER APPLICATION TO:
City of Tigard
Phone:503-710-2972 Email:mattshore(o)sonicom.eom Planning/Engineering
13125 SW Hall Blvd.
Engineer's name: John Cousineau Tigard,OR 97223
Applications for"minor work in right-of-way"
Address: 41.55 SW C Pilar Hills Blvd only may be emailed to:
City/state: Beaverton Zip: 97005 ro=ermits 9tigard-or.nov
Phone- 503-643-0371 Email:_john.cousineau.ftr.com
FOR STAFF USE ONLN
Case No.: P FL�iOI t0 Z
Estimated value of work (within the public right-of-way): .$2,000 -
.Application submittal Eee: c� '
Is work related to a LAND-USE DECISION? ❑ Yes ® No Application accepted: "
If so, please specify(VILP, SDR,SUB, etc.) case#: By: _ Date: >
Is work related to a BUILDING PERMIT? [-] Yes ® Applicad n re .ewed:No Zo�4
If so,please specify(BUILDING PERMIT)case#: By: Date:
Applicant notified:
By: LS Date:
I:\CURPIN\Masten\tend Use Apptatlew ReV.07/16/2014
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwtigard-or.gov • 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) SMALL CERTIFY THAT:
• The aboite r Q est 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.
Qj� /� (� P ---r
John Cousineau 02/29/15
A licant/Authorize 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
500714
FRONTIER
w
11435
11483 SW 90TH 11450
SW 90TH AVE SW 90TH
AVE 32010 AVE
FRONTIER
11491 11475 50'
SW 90TH SW 90TH 11480
AVE AVE AVE SW 90TH
�
50'
17' 1-1 .25"
1-1 .25" 11500
11495 32011 D SW 90TH
SW 90TH FRONTIER AVE
AVE BORE FROM EXISTING
POLE NORTH 17' THEN
CROSS STREET 50'
PLACING 1-1 .25 PVC i
WITH 36" COVER
11540
SW 90TH
w� AVE
11545 SW 90TH AVE Q
0
� 11560
Unl SW 90TH
w I AVE
el-
S0
4 107
kk
8SW Commit Date:2016-03-07
Cust TN: 5034436803/0
Cust Name: GERALD DOLL mpg �x
Addr: 11500 SW 90TH AVE PRT,OR, PORTLAND, OR
County/Twp: /0009-7223
CBR: 5032013018
CO: BBFTP
Commit Date: 2016-03-08
O/T: Order
C/F: Fiber ( A C`
Drop Type:Aerial SIO P P
Temp: No � \1
Drilled Entrance:No
Drop Length: O M
Cross St: Turn \ \
Appr Drop Rte:
Hub: BBFTP/H4003 W Ok%d( to-e—
ICXS _
Strand: V Z 263 `� 0 `t}
Port: 0
Serv. Term: BBFTP/FT-45229 PORT: 0 qeM p41 e- S*`Vk
Drop Term: 11495 SW 90TH AVE PRT,OR 1
Notes: INSTALL 3/08/16 10:00 14:00 1
- ?,-I JOB COMPLETE DETAILS
DATE. NAME: TICKET: EXCH:
P59P DW BORE: LS BORE: SW BORE:
PSOA DIRECT BURY:
P43D PULL:
P77C CORE DRILL: Y N QUANTITY: 1 2 3 4
P16C GROUND ROD: Y N QUANTITY: 1 2 3 4
P71A TRIP CHARGE NOTES:
Y N
-- L10A ( – - -- -
P22K
P36B