PFI2016-00130 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
COMMUNITY DEVELOPMENT Permit#: PF12016-00130
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 06/22/2016
Parcel: SEG984
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Comcast PFI
Project Description: Bore one 3/4'conduit from pole under Scoffins St.then through ROW and up to demark at a min depth
of 30".
Owner: FEES
Description Date Amount
PFI Permit Fee 06/21/2016 $300.00
PHONE:
Contractor:
t
LINESCAPE
19100 SW 51 ST AVE
TUALATIN, OR 97062
PHONE: 503-612-7917
FAX:
Applicant:
RANDY SHIELDS
11308 SW 68TH PKWY
TIGARD, OR 97223
PHONE: 888-824-8264
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:
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12016-00130
Type: Condition Name: Status: Severity:
RECEIVED
City of Tigard JUN 15 2016
PUBLIC WORKS— ENGINEERING CITY OF TIGARD
• , � (PFI) ��NGINEERING
Public Facility ImprovementPermit
DESCRIPTIION OF WORK (in the right-of-way) TYPE OF WORK
'I-
Check one: lTtitilin Connection TYPE 1-Franchise Utility Work
ElSidewalk/driveway approach Work performed by N\\-N,PGI:
❑ Street improvements and/or utility agene)•.
a/ r•
Detailed description: �nly n4Q-, "� Covl ,. 4,-Orn Pa1R 0 TYPE 2-Sidewalk/Dri,eway/Sewer
1ka d-LI Seo S+ +—Vy r �91�� ac V\j -�v c(-p Work performed for the purpose of-.
JD ala' 6- a ,)n p_" a0 � l'til • • Sidewalk installation or repair.
• Drivevyay approach installation
�, �
Property address/location(s): k2 Coq 0 SW wand/or repaira-v n ��
nn • Sanitary sewer lateral installation
S E U �� A f d- O `� 2 23 and main line tap
❑ TYPE 3-Full scale Development
Applicant,' L.0 IAC 4L-5+ approval
t/ Work performed with Land use
Address: 1)3 0 � SW ��+1"'PI, "I approval which includes any of
the following:
City/state: oil> Zip: 3 a a Subdivisions or Partitions
Phone - 2� Email: .Ca • Street widening
Contact name: I ,le, Phone: 1`y_Ifi-
• Nlainhne installation for Sanitary
! 1 sewer,Storm sewer,Tigard water
Contractor: `L C, and/or Tigard Water Service Area
CCB#: 1 L�o q U Expiration: R/l I% T SUBMIT COMPLETED APPLICATION TO:
Address: I ci i cO S VY , ) S- A yf-,, • nCity of Tigard
City/state: 7 G otJ,c--fXY\ ( zip: -1 0(9 Planning/Engineering
y3-(22-2 9l-} Email: ��t rv�1 cS�l��E Sia PeL(C coca. 13125 SW Hall Blvd.
Phone: `J Tigard,OR 97223
Contact name: Phone: Applications for"minur work in right-of-way"
only may be cmailed to:
Engineer:
toHn
• errnits(ktigaa-Lg9v
Address: _—
City/state: Gil': P FL 2,01 1!O -001.3 0
Phone: Email: Case No.:
Contact name: Application submittal fcc:
Additional fees: _---
Estimated value of work is required(if over$5,(100):$ Application accepted:
Ip/ J
(utithin the public tight-of-way) By: Date: ------
Application reviewed:
Is work related to a LAND-USE DECISION? ❑ Yes No ,I l. � _ � Date
By: L :Ar--a-?r
If so, please specify (MIT, SUR, SUB, etc.) case #:
Applicant uxilu•d:
Is work related to a BUILDING P1;R1\11Te El Yes --(3 No By: S Dace:
If so,please specify(BUILDING PER, I'l)case#: t.\CURPLHva�te,,\t,"euuwawMoM P�orrovnou
City of Tigard • 13125 SW l fall blvd. • "Tigard,Orcgon 97223 a•vw.tigard-or.gov • 503-718-2421 • Page 1 of 4
LvI�YLrt� — �Up Yi�A�l�t� t2f-STt2iLT"tettS Le�"A%" —q' A-,, 04, 3ru, — GPM,
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 posseuion with written
authorization from the owner or an agcot of dhc owner. The owncr(s)must sip this application in the space provided or submit a winces
authorisation with this application.
BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT:
• The above rcQuest does not violate any deed restrictions that may h`attached to or imposed
• 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,arc 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 gbh owner of the subject property required.
j2ap Z21L1Jj—
plicas orized Agent's signature Print name Date
Own s' cure Print name Date
eJe signature Print name a 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
Public Facility Improv=ement (PFI) Permit: SUBMITTALDETAILED
APPLICATION FEE
Part 1: Required submittal fee S300.00 FRANCHISE UTILITY AND SIDEWALK/
PERMIT FEE DRIVEWAY AND UTILITY
CONNECTIONS,ETC.
Part 2: 1111 non-water system improvements (work in the right of way)
Engineer's estimate X 51'/4 (less$300.00 submittal fee)
Engineer's estimate X 2°/4 Plan Review Sketch
(including information below)
WATER SYSTEM FEE ❑ Dimensions
Part 3: All public water system improv=ements ❑ Street Name
Engineer's estimate 1 12%, ❑ Site Address
PFI Permit Fee Exemptions:
There will be no permit fee charged,or assurance required FULL SCALE DEVELOPMENT
(Subdivisions/!'orations and Street Improvements)the following types of work:
• Sidewalk repair(less than 20 lineal feet)
• Relocate or replace mailbox Design Plans
• Ditch cleaning that does not involve regrading. ((i secs,24x36 or 22x34)
• Weephole repair ❑ Cover—Site,Vicinity,Abbreviation,Legend
• Curb repair or replacement(less than 20 lineal feet) ❑ General Notes(City,Water,Sewer,etc.)
• Lawn sprinkler system installation or repair ❑ Street(Plan,Profile)
• Street tree pruning or planting ❑ Water,Storm and Sanitary(Plan Profile)
• Planter strip landscape maintenance ❑ Mater Quality I-acilides
• 'fest wells ❑ Grading
❑ I..andscaping/Tree Plan
❑ Composite Utility Plan (Electrical,Phone,Gas,
Note: A cash assurance may be required per Storm,Sanitary,\eater,Signage,Street Lights,etc)
TMC 15.04.140.(customer deposit) ❑ Details
Cl Traffic Sight Distance
❑ Signing and Striping
❑ Street Light Plan and Photometric
❑ Engineers seal/signature
❑ Sheet label(project land use name,revision and
plan log block,dates and sheet numbers.)
Additional Submittals
(peer I-and Use conditions)
❑ Traffic Report
❑ Storm crater Drainage Calculations
❑ Geotechnical Report
❑ Preliminary Access Report (Sight Distance)
❑ Proposed Plat
❑ Pathway Design (if applicable)
❑ Water Department Approval
PUBLIC FACILITY IMPROVEMENT PERMIT
City of Tigard 13125 SW Hall Blvd. • Tigard,0rcgon 9 22 3 • www.titgard-or.gov 503-71$-2421 • Page 3 of 4
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Page 84 2011 Edition 2011 Edition
Pogo 85
Sta'ono ne Crolosure
$ tionary Lane.Cics_ur,��virith Fla ging :�-.�,+1]iagram;3�0
Diagram 320 covers total closure of one lane of a two-lane,two-way
roadway. See the detail inset for the layout if using a single flagger to control I Q
both directions of traiflc on low volume roads(less than 400 ADT)with good a3 0
sight distance as discussed below. C
1. Use truck-mounted flashing warning lights on work and protecUonCL
vehicles. See Section 4.3-Lights and Lighted Signs for exceptions. O
2. For added visibility,a truck-mounted arrow board or PCMS in caution _ co
X11 U-
U-
3.
may be used.
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3. Flaggers at each approach are required if any of the following
conditions exist: g
a. Night Operations. •�c _
b. Work space is over 200 feet in length. �L—
c. Sight distance is less than 750 feet from each approach
--
through the lane closure,.
d. Traffic volumes are greater than 400 ADT. I d I I •• >
I I I
d. The length between the Flogger Ahead signs shall not exceed one I ' l t I •
mile. Use Diagram 340—Lane Closure with Pilot Car if exceeding one I I I
mile. I I
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i I I • ;
5. Cones should be used to ouOlne the work space when curves or other $ !® ��! I '•
roadway alignments prevent clear direction for the motorists to pass
the work space safely.
6. Cones along the work space are recommended when posted speeds i O �. �i I • _L
are 45 mph or greater,when working under heavy traffic or when travel -0 v I
lanes are narrower than 11 feet. j mil:
• I
7. Extended queue signing(see Diagram 54)should be used when
traffic queues extend beyond the initial advance warning sign.
I W tt� d I
8. When flagging near an intersection,the"Flogger Ahead"(CW23-2) --------
- 1-------
sign should be visible to traffic entering from any side road. Additional � I 1 � �
advance warning and Flagger Ahead symbol signs may be placed on S19- 1 Sp-t and ewwt—gtn.lt••V \
the side road(s). ,Poo d ..n. .� , urtm
ERRAiA: �tAotu 'asr�,�. , •8•.`".
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20 50
9. Sign set-up and(!agger placement shown may be used for intermittent Supp--tT.61. is 100 110 1W s
full road closures of 20 minutes or less. a0 1W
35
10.The'ONE LANE ROAD AHEAD'(W20-4)sign is optional and should 11 �-•, ;s350�
be considered on high volume or high speed roads,or when extended w soo mo SM
queues are expected. I
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