PFI2017-00101 a
CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT
= COMMUNITY DEVELOPMENT Permit#: PF12017-00101
13125 SW Hall Blvd .Tigard OR 97223 503.718.2421 Date Issued: 06/07/2017
Parcel: SEG739
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: NW Natural
Project Description: Adjacent to 11890 SW Wilton Ave. Replaced 2' poly main due to damage. Main on the 5.5' in ROW.
One 4'x 5' hard surface cut to make repairs. SEG 739/WO#3493597.
Owner: FEES
Description Date Amount
PFI Permit Fee 06/07/2017 $300.00
PHONE:
Contractor:
LOY CLARK PIPELINE CO
PO BOX 1369
TUALATIN, OR 97062
PHONE: 503-644-2137
FAX
Applicant:
SHELLY KIRSCHENMAN
220 NW 2ND AVE
PORTLAND, OR 97209
PHONE: 503-226-4211
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: See application
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for PF12017-00101
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 twenty-four(24) hours prior to commencing work,prior to any staged
inspection, and after completing work covered by the permit. call Ken fisher 503-816-6146 or Kenny@tigard-or.gov
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
RECEIVE®
City of Tigard
JUN 0 6 2017
PUBLIC WORKS — ENGINEERING CITY OF TIGARD
NINGTNOMI-RING
p
Public Facilityimprovement (PFI) Permit
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TYPE OF WORK
DESCRIPTION OF WORK(in the right-of-way) TYPE 1-Franchise Utility Work
Check one: ❑Utilities ❑Sidewalk/driveway approach ❑Street improvements performed by NWN, PGE
Detailed description:
Replaced 2'poly main due to damage. Main on the and/or utility agency.
5.5'in ROW. One 4'x 5'hard surface cut to make repairs. ❑ TYPE 2—Sidewalk/Driveway/Sewer
WO#: 3493597 Work performed for the purpose of:
• Sidewalk installation or repair.
Property address/location(s): 11890 SW Wilton Ave • Driveway approach installation
�-n and/or repair
q
S 6171 3"1 • Sanitary sewer lateral installation
and/or main line tap
Applicant: NW Natural/Shelly Kirschenman TYPE 3—Full scale Development
PP El Work performed with Land use
Address: 220 NW 2nd Ave approval which includes any of
City/state: Portland OR Zip: 97209 the following.
Phone: 503-226-4211 x4347 Email: smk@nwnatural.com • Subdivisions or Partitions
Contact name: Shelly Kirschenman Phone: • Street widening
• Mainline installation for Sanitary
Contractor: Loy Clark/Jim Fitzgibbon sewer, Storm sewer, Tigard water
and/or Tigard Water Service Area
CCB#: 52281 Expiration:
Address: PO Box 1369 SUBMIT COMPLETED APPLICATION TO:
City/state: Tualatin OR Zip: 97062 City of Tigard
Phone: 503-664-2137 Email:jim.fitzgibbon@loyclark.com Planning/Engineering
13125 SW Hall Blvd.
Contact name: Jim Fitzgibbon Phone: Tigard,OR 97223
Applications for"minor work in right-of-way"
Engineer: Richard Girard only may be emailed to:
Address:
Same rowpemiitsatigard-or.gov
City/state: Zip:
Phone: 360-921-0314 Email: R2G@nwnatural.com Case No.:Ptr I U n-WI o I
Contact name: Application submittal fee: $ 300•ao
Additional fees: $
Estimated value of work is required(if over$5,000):$ Application accepted:
(within the public right-of-way) By: f"V Date: (2 1-7
Is work related to a LAND-USE DECISION? ❑ Yes ❑ No Application reviewed-
If
7
If so,please specify (MLP, SDR, SUB, etc.) case #: By: .)�i3�. Date:
Applicant notified:
Is work related to a BUILDING PERMIT? ❑ Yes ❑ No By: Date:
If so,please specify(BUILDING PERMIT)case#: I:\ENG\PermitApplications\pfi_appllcation Rev.12/16/2016
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-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,if
required by the city pursuant to TMC 15.041.140.
* With the exception of a utility operating pursuant to a valid franchise with the City of Tigard,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. Franchised
Utilities are not required to obtain the owners signature on the application
BY SIGNING BELOW,THE APPLICANT(S) SHALL CERTIFY THAT:
• The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject
prope
• 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 any 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.
D italy signed by Shelly D�,ee ail=s k@ate 2017.02 06'sna 41 2e-0, Sa�r•,, Shelly Kirschenman 6/6/2017
Applicant/Authorized Agent's signature Print name Date
SIGNATURES of each owner of the subject property,if required.
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 • Puge 2 of 4
DEVELOPMENT ENGINEERING FEES FOR STAFF USE ONLY
Public Facility Improvement(PFI)Permit: DETAILE-D SUBMITTAL
APPLICATION FEE REQUIREIINIENTS
Part 1: Required submittal fee$300.00 FRANCHISE UTILITY AND SIDEWALK/
PERMIT FEE DRIVEWAY AND UTILITY
Part 2: All non-water system improvements CONNECTIONS,ETC.
Engineer's estimate X 5%(less$300.00 submittal fee) (work in the right of way)
Engineer's estimate X 2%Plan Review Sketch
(including information below)
WATER SYSTEM FEE ❑ Dimensions
Part 3: All public water system improvements ❑ Street Name
Engineer's estimate X 12% ❑ Site Address
PFI Permit Fee Exemptions: FULL SCALE DEVELOPMENT
There will be no permit fee charged,or assurance required
(Subdivisions/Partitions and Street Improvements)
for 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. (6 sets,24x36 or 22x34)
• Weep hole 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 ❑ Water Quality Facilities
• Test wells ❑ Grading
❑ Landscaping/Tree Plan
❑ Composite Utility Plan(Electrical,Phone,Gas,
Note: A cash assurance maybe required per Storm,Sanitary,Water,Signage,Street Lights,etc)
TMC 15.04.140.(customer deposit) ❑ Details
❑ 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
(per Land Use conditions)
❑ Traffic Report
❑ Storm water 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,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 3 of 4
SAMPLE SKETCH:
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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 • www.tigard-or.gov • 503-718-2421 • Page 4 of 4
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CT
NW Natural PLAT: 1-042-015 COUNTY:WASHINGTON 06/06/17 07:4
(503)226-0211 TOWNSHIP: T01S RANGE: R01W SECTION: 33SW SCALE: 1 IN= 100 FT USER ID:smk
(,) NW Natural ' Standard Construction Completion
Created By NNG\smk Created On 6/5/2017 6:22:00 PM
Job Number Address Host Job Number
NWN-20170105-01200 11890 SW WILTON AVE, PORTLAND OR 97223--166 03493597
Installation Information
Completion Date Pipe Type Pipe Size Installed Fta Abandoned Casing Ftg Extra Equip Grd Post
01/05/2017 POLY 1/2 2 YES 0 YES 0
Pipe As-Built Information
Pressure Pipe Pressure Test Pressure Test Test Gauge ID# Station Ftg Connect Loc Connect Type
Tested Tested At Date Time Duration
YES 100 01/05/2017 13:45:59 10 1400 0 SERVICE PEMRWL
Anode EFV Manuf Valve Install Date Short/Lona Meter Status
L EO
Installation Type Installation Method Construction Methods Houseline Status Curb Valve Installed In/Out/
Feet On
REPLACED EXCAVATE NG 0
Riser Installed? As Built Remarks
NO DAMAGE REPAIR SONICOM MATT SHORE 1275 S KODIAK CIR. CORNELIUS OR 97113 LOCATES
WERE VISIBLE AND CORRECT
Has a defect been discovered? Did you repair a leak? Paving-Restoration Reauirements
NO YES NOT COMPLETE
Depth/Separation Information
Location Exposed? Depth Station Separation Variance? Event#
Riser NO 0 in. NO 120922
Tie-In NO 0 in.
Mid-Point YES 24 in. 0+49 YES
Pipe to Soil Information
Reading: 0.000 Completed By: Instrument Number:
Pipe Inspection Information
Location: WILTON AVE 163 ft. NORTH of MORNING HILL
Length Cover Facilty Facility Type Material Above/Below Pressure Class Existing
Exposed Depth Ground Pipe Size
3 24 SERVICE PIPE POLY BELOW Distribution 1/2
Unusual Corrosion Conditions Other Comments
External Pipe Inspection Information
Corrosion Level Erosion Pit Depth Pit Diameter Tracer Wire
NONE 0.000 0.000 p
Coating Condition Existing Coating Soil Conditions Cover Type Tracer Wire Condition
NA N/A Clay Asphalt GOOD
Recommendation for Further Action
Report Name:Z_DEF_CONSTRUCT, Server:http://fame/ReportServer Page 1 of 2
NW Natural Standard Construction Completion
Created By NNG1smk Created On 6/5/2017 6:22:00 PM
Job Number Address Host Job Number
NWN-20170105-01200 11890 SW WILTON AVE, PORTLAND OR 97223--166 03493597
Internal Pipe Inspection Information
Corrosion Level Erosion Pit Depth Pit Diameter
NONE 0.000 0.000
Recommendation for Further Action Action Date Action Time
01/05/2017
Common Information
Ori in Job Type Emel#-Login FieldReportNumber Received Date Time Processed Date Time
EAM 20170105 096337 -T5C NWNM468020170105140015 01/05/2017 14:28:12 01/05/2017 22:45:00
Class Plat ID Prow ct Number Cost Center Old Abandoned
336 1-042-015 WO_03493597(0010) 0
Resource Center Dispatch Area Latitude Longitude
01 -Sunset 0104- Beaverton 45.4340304 -122.81954808
Report Name:Z_DEF_CONSTRUCT. Server:http://fame/ReportServer Page 2 of 2
(,) NW Natural ' Construction Cause of Leak
Created By NNG\smk Created On 6/5/2017 6:25:54 PM
Job Number Address Host Job Number
NWN-20170105-01200 11890 SW WILTON AVE, PORTLAND OR 97223--166 03493597
Material Failure/Defect Report General Information
Completion Date Addr Chi NNt r Pre Street Tvoe Post ADpt
01/05/2017 NO 11890 SW WILTON AVE
City ZipCode Plat ID
PORTLAND 97223-1661 1-042-015
Cause of Leak Information
Known Leak Site ID/Hazardous/Non-Hazardous Did you Cause of Leak Non-Verified Cause of
Grease. Lube Leak
or Tighten
NO HAZARDOUS NO EXCAVATION
Cause of Leak Comments
DAMAGE REPAIR SONICOM MATT SHORE 1275 S KODIAK CIR. CORNELIUS OR 97113 LOCATES WERE VISIBLE AND
CORRECT. 1% GAS IN STRUCTURE PGE CUT POWER SO FD COULD VENT
Common Information
Ori in Job Type Empl#-Login Field ReportNumber Received Date Time Processed Date Time
EAM DMGM2 096337-T5C NWNM468020170105142855 01/05/2017 14:30:17 01/06/2017 06:06:00
Event#
120922
Report Name:CST_CAUSE_OF_LEAK, Server:http://fame/ReportServer Page 1 of 1
(,) NW Natural ' Damage to Gasco Structures - Repair
Created By NNG1smk Created On 6/5/2017 6:27:21 PM
Job Number Address Host Job Number
NWN-20170105-01200 11890 SW WILTON AVE, PORTLAND OR 97223--166 03493597
Damage to Gasco Structures Information
Damage Date Damage Found Gas Gas Controlled Re it Interrupted Damage Type
Depth Controlled Completed Customers
01/06/2017 18 12:46:45 03:10:56 2 BROKEN
Location Damaged Facility Damaged Facility Other
OUTSIDE—PL SERVICE
Material Pre-Located Pre-Located Other
POLYETHYLENE YES—CORRECT
Was work done in ROW? Hard Surface Cuts Size of Cuts in Hard Surface
PAVEMENT 1 3X4
Explanation of Repairs Made and Materials Used
CUT STREET TO SQUEEZE PIPE 4 LYCO COUPLINGS 3FT POLY
Equipment Information
E ui ment Hours Equipment Hours Equipment Hours
CREW-TRUCK 5.00 MINI-EXCAVATOR 5.00 0.00
Equipment Hours Equipment Hours Equipment Hours
0.00 0.00 0.00
Misc Expenses and Additional Personnel Information
Paving Cut Size Sand Gravel Dump Concrete
Welder Hours Field Data Hours Leakage Inso Hours Sery Tech Hours
0.00 0.00 0.00 0.00
Common Information
Origin Job Type Empl#-Login FieldReportNumber Received Date Time Processed Date Time
EAM 096337-T5C NWNM441820170106081011 01/06/2017 08:13:27 01/06/2017 0838:06
Plat Id Event#
1-042-015 120922
Report Name:ER_DAMAGE_REPAIR, Server:http://fame/ReportServer Page 1 of 1