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PFI2018-00346 CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT = COMMUNITY DEVELOPMENT Permit#: PF12018-00346 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 12/31/2018 Parcel: SEG1154 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: NW Natural PFI Project Description: Installing 203'2"(P) Main in ROW and Private property to bring new 1"service to 12800 SW Pacific HWY. 2 Standard street cuts required. Owner: FEES Description Date Amount PFI Permit Fee 12/2812018 $300.00 PHONE: Contractor: PHONE.- FAX: HONE:FAX: Applicant: JAMISON FORGE 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: , ' C�,�►(J(,(((-Jn I--)— Issued By: An%A/) i Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12018-00346 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 Jonny Gish 971-713-0281 or Jonny@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 RECEIVED City of Tigard DEC 18 2018 PUBLIC WORKS —ENGINEERING CITY OF TIGARD ANN1ING N G I N E E R I N G Public Facihty Improvement (PFI) Pernut TYPE OF WORK DESCRIPTION OF WORK(in the right-of-way) ❑ TYPE 1–Franchise Utility Work Check one: 0 Utilities ❑Sidewalk/driveway approach Q Street improvements performed by NWN, PGE Installing 203'2" P main in ROW and Private property and/or utility agency. Detailed description: g ( � p P y to bring new 1"(P)service to 12800 SW Pacific Hwy.2 standard street cuts ❑ TYPE 2–Sidewalk/Driveway/Sewer required. Work performed for the purpose of: - Sidewalk installation or repair. Property address/location(s): 12800 SW Pacific Highway - Driveway approach installation and/or repair - Sanitary sewer lateral installation and/or main line tap Applicant: NW Natural ❑ TYPE 3—Full scale Development pp 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 x4542 Email: Jamison.Forge@NWNatural.com - Subdivisions or Partitions Contact name: Jamison Forge Phone: 503-226-4211 x4542 - Street widening - Mainline installation for Sanitary Contractor: Loy Clark 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 Planning/Engineerig Phone: 971-806-2841 Email: Jade.leedy@loyclark.com 13125 SW Hall Blvd. Contact name: Jade Leedy Phone: Tigard,OR 97223 Applications for"minor work in right-of-way" only may be emailed to: Engineer: rowpermits�1igard-or.gov Address: City/state: Zip: Phone: Email: Case No.: Contact name: Application submittal fee(.007%of Engineer's Estimate) $:K 430 Estimated value of work is required(if over$5,000):$ Additional fees: $ oe (within the public right-of-way) Application accepted: Z By: JM (Z> Date. ` Is work related to a LAND-USE DECISION? ❑ Yes O No If so,please specify (MLP,SDR,SUB, etc.) case #: Application reviewed: r-Z— ?f r By:y �+S� Date: Is work related to a BUILDING PERMIT? ❑ Yes 0 No Applicant notified: If so,please specify(BUILDING PERMIT)case#: By: Date: I:\ENG\PermitApplications\pfi—application Rev.10/16/2017 City ofTigard - 13125 SW Hall Blvd. - Tigard,Oregon 97223 - www.tigard-or.gov - 503-718-2421 - Page 1 of4 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 APPLICANTS) SHALL CERTIFY THAT: • The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject ro e • 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. Digitally signed by Jamison Fore 12/18/2018 Jamison Forge g 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 `r t c 1 ffi-.;..s.;. ..:..:..,v�'a.'4=ciL.•..:.f?:d!1R.Y31e`YMs.:..:a:2*etisww.'_.:Siss.R :...u.:.;r. W-.v.2.x.Y"f3. Y.t:.':,t :;..:'-..+�,..,:':.,:wa't AsfSVi.K4".i'i%.td. .'e:?.ti.'. d..n.:..Mi, ;: - ...d'�.sP-J Y�F`.X1YY,`:JS}a.ICY%76e'YiXiB1$f!JLCa1�.SYie:.e'iiA�ai3Y+�'6_AtL'+iW,s«.i.c PUBLIC FACILITY IMPROVEMENT PERMIT City ofTigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov 503-718-2421 Page 2 of4 DEVELOPMENT ENGINEERING FEESFOR STAFF USE' ONLY Public Facility Improvement(PFI)Permit: DETAILED REQUIREMENTS APPLICATION FEE Part 1: Required submittal fee$300.00 (minimum) FRANCHISE UTILITY AND SIDEWALK/ DRIVEWAY AND UTILITY PERMIT FEE CONNECTIONS,ETC. Part 2: All non-water system improvements (work in the right of way) Engineer's estimate X 5%(less$300.00 minimum submittal fee) Sketch Engineer's estimate X 2%Plan Review (including information below) ❑ Dimensions WATER SYSTEM FEE ❑ Street Name Part 3: All public water system improvements ❑ Site Address Engineer's estimate X 12% FULL SCALE DEVELOPMENT PFI Permit Fee Exemptions: (Subdivisions/Partitions and Street Improvements) There will be no permit fee charged,or assurance required for the following types of work: Design Plans • Sidewalk repair(less than 20 lineal feet) (G sets,24x36 or 22x34) • Relocate or replace mailbox ❑ Cover—Site,Vicinity,Abbreviation,Legend • Ditch cleaning that does not involve regrading. ❑ General Notes(City,Water,Sewer,etc.) • Weep hole repair ❑ Street(Plan,Profile) • Curb repair or replacement(less than 20 lineal feet) ❑ Water,Storm and Sanitary(Plan Profile) • Lawn sprinkler system installation or repair ❑ Water Quality Facilities • Street tree pruning or planting ❑ Grading • Planter strip landscape maintenance ❑ Landscaping/Tree Plan • Test wells ❑ Composite Utility Plan(Electrical,Phone,Gas, Storm,Sanitary,Water,Signage,Street Lights,etc) ❑ Details Note: A cash/bond assurance maybe ❑ Traffic Sight Distance required per TMC 15.04.140. ❑ Signing and Striping (customer deposit) ❑ Street Light Plan and Photometric ❑ Engineers seal/signature ❑ Sheet label(project land use name,revision and plan log block,dates and sheet numbers) Additional Submittals (per Land Use conditions) ❑ Traffic Report ❑ Storm water Drainage Calculations ❑ Geotechnical Report ❑ Preliminary Access Report(Sight Distance) ❑ Proposed Plat ❑ Pathway Design(if applicable) ❑ Water Department Approval ❑ Engineer's Construction Estimate R3 ,;.:';.}ryrc '. _-.A'�' - rz. . o:Sti`.PEW,'�' dd7:`�.�i �{1$:X?1e"F�`.a"l:A.'8sd.Udt�;;x.(wii�{EMr5a"'>w'h�8`ir+: .-. �k'SS-ia�:K+&�+9k ,71w:bin'Yf4.nX'.wMl£V�&K38�f$I9M:1•ICY.tF �$l��d:= 9H14T8n'i-�XKe`..:.': PUBLIC FACILITY IMPROVEMENT PERMIT City ofTigard 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 3 of4 SAMPLE SKETCH: Edge of Pavement I I � Ditch Streetlight •—•—•-------•—•—r--- I o a 1 � I • ' T propos d''Se+wer'Tine all I 1 NI Existing House Existing a� I Zi Driveway 01 Lo 13L I q:;r! ap d 1 o13� I 1 ,asp I �+ L � - °'' I 1 I . Existing Shop C • Powerpole I a 1 95' --------7rcpertyLin _e ------ -—- � I . o I ' Fire Hydrant(FH) I I I I Scale: 'I"=30' 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 ofTigard - 13125 SW Hall Blvd. - Tigard,Oregon 97223 - www.tigard-or.gov - 503-718-2421 - Page 4 of NW Natural— Site Information Form (SIF) Service Address Service WO# 12800 SW Pacific Hwy 3555834 Plat# City and County Main WO# Revision# 1-043-019 ]Portland, Washington 3555833 LOCATE INSTRUCTIONS: Have pre checker put white locate brackets down. White Paint Down?F—E YES kK NO How many Headers? Delivery Pressure Total Therm Load Q(Single❑ Double ❑Other#: ❑Standard V2 PSI ❑Other: �113 ❑ Residential �6 Commercial ❑ Industrial ❑Conversion ❑Riser Relocate ❑Cutoff qf New Const ❑Open Pathway(open) 46 Conduit ❑RUSH ❑PRESOLD ❑Bore w/crew ❑ Bore-N-Go ❑GNS ❑ Double Off ❑Job Agreement ❑ Easement Required PERMIT REQUIRED ❑ NONE 0 City - ❑Sticker - ❑Verbal - ❑ Notify Only - ❑Blanket - ❑Standard ❑County ❑ODOT/WSDOT ❑ Railroad ❑Other(specialty permits,easements): ❑Traffic Control Plan Needed 14 Standard ODOT template attached ❑Vendor-provided plan ❑Flagging required INSTALLATION REQUIREMENTS 0 See Separate Attachment Service Size&Type Service Footage 1" Poly 30' Main Size&Type Main Footage 2" Poly 189' Service to Main Location VShort V Long Hard surface cuts required? YES [CI NO Street Moratorium? FTYES I—CI NO Guard Post Required? rO—YES QZI NO Fiber Optics? V Unknown FYES P NO Oil Tank? IV Unknown YES El NO Septic Systems? V Unknown YES CI NO Sprinklers? Unknown Ca,YES FCl NO Other(list): V1 Unknown C YES CI NO Houseline Installed: JE YES QZI NO Meter Loc: LEOS ❑Green Tagged Working within open water area? r YES JZ NO Erosion Sensitive Area? YES 10 NO Working within proposed or existing planter strip/swale? FE YES 10 NO Working in a Tree Critical Root Zone? YES 10 NO CROSS SECTION DETAILS Paving Symbols: AC—Asphalt E—Earth C—Concrete G—Gravel PUE—Public Utility Easement,ROW—Right-of-Way,EOP—Edge of Pavement,C/L—Centerline Comments ao O O 0a CURB? Y / N CURB? Y/ N Number of cuts: cL Size of cut(s):: ❑Over main ❑Over other utilities Street Name: Direction Facing North ❑West F-8039(5/17/2017) REMINDER:ALWAYS COMPLETE PAGE 2 OF THIS FORM Description Service Estimated Hours Main Estimated Hours wo#: 3555834 wo#: 3555833 Crew comp Construction 4 Construction 3 X X Construction 2 X X Construction 1 X X Equipment/Other Labor Mini-Excavator, 3 Yarder&Trailer X X Bore Machine Contract Dump Truck 10 Yarder Vac-X Truck &Crew Mechanic Welder&Truck Flagger—how many? 2 Plate Truck Miscellaneous Contract Sawcut X Other: Other: Other: NOTES(Construction details,ground conditions,etc.) City permit needed, 2 flaggers needed, saw cutter needed, have pre checker put white locate brackets down. Estimate is for 189' 2" poly main extension across and down Mckenzie st in 5' earth strip between curb and sidewalk, and 30' 1" poly service with a 2600 EFV and 1" riser with by pass, see attachments. Name: Date: Curtis Babcock 10/12/18 F-8039(511712017) CUSTOMER: w"w,w'^ SPEED NWNG V KBD Services,as the preparer of this traffic i.Maintain Ped.access to uMIT / control plan makes no representation as to its' and through crosswalks 35 CONTACT: general adequacy or being approved for implementation. and or sidewalks. ROAD / Curtis Babcock Approval must result from the Traffic Engineer or 2.Maintain Min.f0'lane WORK / 971-352-5166 other Public Official having statutory enforcement authority 3.Maintain Local access AHEAD in the jurisdiction.Utilization and implementation of this 4.Traffic Control Plan and all / LOCATION: plan shall be a result of that approval. devices shall comply with the / 12800 SW Pacific Hwy Ref.MUTCD 2009 6A-01(10) 2009 MUTCD and 0TTCH 2011 / r Tigard,Ore standards. r on 5 r g g ��� .Device spacing Flag taper 20' DATE: W/o# All other tapers equal to the / / INVENTORY: 10/16/18 3555833 posted speed.20'min.for tangent 8.28"cones 4 Road Work Ahead Sh, 38"barrels / DESIGNED BY � ,�c 48"signs w/Flags yo � � 1 Be Prepared To Stop JOE KOUBEK k�� 7.Cover stop signs and/or disableF-1 1 Flagger Ahead K&D Services \_ ?iP lights when at a controlled intersection Qat / g g Traffic Management jkoubek@kndservices,net Sf 8.Place No Parking signs 48 hrs in advance. y1 1 Lane Closed PHONE:503-723-7287 503-723-7287 ext 1015 `.� 9.Adjust to field conditions. / 5 FAX:503-723-8750 / 1 Type 3 Barricade ORTCP@kndservices.net I ORTCP@kndservices.net 1 Flagger NOTIFY POLICE, FIRE 1 Monitor AND EMS ROAD , 30 Cones WORK 72 HOURS IN ADVANCE AHEA � loo• PLEASE SCHEDULELANE MONITOR TO ASSIST WITH , /i CLOSED SWITCH CONTROLS TO WITH DISPATCH PEDESTRIANS AND TURNING / OTHER SIDE OF ROADWAY @ 503-723-7287 VEHICLES;ALSO ! AS WORK ZONE CHANGES, 4 DAYS IN ADVANCE COMMUNICATING WITH THE / IF NECESSARY FLAGGER WHEN TO HOLD TRAFFIC. , AND PROVIDE A ;' r sy r Rev Requested By: Description Date By COPY OF THE APPROVED TRAFFIC CONTROL PLAN / C NWNG Change Trench to Bore, 12/27/18 JEK MAINTAIN ACCESS ! Change Road Closed NOT TO SCALE TO BUSINESSES / / •• • Ahead to Road Work Ahead on SW McKenzie, / Remove Road Closed / BORE PITS from Type III,Add Lane / FOR MAIN Closed on Stand _-. . / EXTENSION 50'Flagger Taper 100, Legend �@ Cones Lane Width 12' sf 100, Flagger I-� ® Flagger Ahead Posted Speed 35/25�l BE/ PREPARED Traffic Monitor TO STOP ROAD WORK STYPE III BARRICADE Sign Spacing 350'/100+/- , AHEA C>W20-1 roadwork ahead Flagger Taper 50' , lour NOTIFY POLICE, ® �W20-7b be prepared to stop SPEED FIRE&EMS LIMIT ® or Wk Area Devices Taper 20 ROAD 72 HOURS IN ADVANCE p WORK 35 NOT TO SCALE / s , Devices Tangent 20' "E" CROSS SECTIONS GENERAL NOTES N 80' 1.Call the following Utilities Notification Center -- �—•– - 48 hours prior to any excavation: J 6' 34' 34' 6@ J Oregon: 811 or 1-800-332-2344 WE Washington: 811 or 1-800-424-5555 L -p (D -p 2.ATTENTION:Oregon law requires you to follow c p C p rules adopted by the Oregon Utility Notification S C W W B L B IX W C Center.Those rules are set forth in OAR 952-00 1- 0090.You may obtain copies of the rules by calling the center.(Note:the telephone number for the Oregon 1 _41.0 Utility Notification Center is(503)232-1987 or 811 3.Fill out construction sketch as-built supplied with job packet and return with work order. Only one W/S SW PACIFIC HWY E/S as-built is required. 4.All distribution mains must have a minimum depth of 40' 24"and services must have a minimum depth of 18" /fly / X69 ,& LOO �1 —` unless there is an approved variance. o, $' 12' 12' $' 5.All transmission lines must have a minimum depth of /jCL L 30"in Class']'locations and 36"in Class'2,3,&4' J �s�J o �C o co CM O locations,unless there is an approved variance. t1°'/ �\ E W B C L B 0 W C 6.Written dimensions on this construction sketch QO 'LrO s Q, �sp 00000 have precedence over scaled dimensions. �� icy G 7.Pressure test shall be tested in accordance with ° tijyy /jjf standards in CFM and Engineering Standard Practice. .4t' �q s G -- 0� 3� 8.Test medium for class"B"main shall be air,unless Mi � 6ti otherwise noted. Test medium for class"C-F"main T#;? S/S SW McKENZIE S T N/S shall be water,unless otherwise noted. 14f? 9.For Class C or higher tests,see Design Document and Hydrostatic Report. INSTALL:.- tk 0, �°° ❑ LW ti� � . &s / pox�xo tx1 �lz!�>� � ox Class "B" PRESSURE TEST INFORMATION(circle & label test area on as-built drawing) / xo x o�o`� is INSTALL: Test by NNG— Other �,��w / ❑ TF W/LW& TL Test Area Size Poly- F ottase Pressure Date Pipe Tog ON Tyne Date t F Time PASS / �� `' e Steel pause M Print Name and initial A ❑ 1#Anode i C °ti G��9?' #ss��i x6,6 S� D s<< s° Q0 x N` �� E eo F ° --INSTALL: Order Street Description Plat number Costing Pipe size Type ❑ LW 3555834 12800 SW Pacific Hwy William Warren Properties Inc(SAS) 1-043-019 2720 P-0100 SM03 INSTALL. WELDS 2600 EFV X- CERT. OPER. PM PM FOOTAGE SIZE M P GRADE W.T. RAYED MAOP MAOP NOP ACTIVITY# ORDER# INSTALL 203' 2" P B P24 .216 60 57 45 710 03555833 ' NW Natural 50 100 Feet Engineering Department 1 in = 100 ft ADDRESS CITY COUNTY STATE DESIGNED CFB DATE 10/12/201 12800 SW PACIFIC HWY TIGARD WASHINGTON OR DRAWN KDC DATE 1211712018 VARIANCE (S) BETWEEN AND SW McKENZIE ST SW McKENZIE ST APPROVED R2G DATE 121181201 Variance(s)made NAME CREW LDR. DATE 12800 SW PACIFIC HWY MX PLATTED DATE Reason{s): PLAT TWN RNG SEC PIPELINE ID- JOB TYPE: Mitigation taken (A any): 1-043-019 T02S R01 W NW 2 NEW CONSTRUCTION MAINS PM#: PROJECTIREVISION# 03555833 00022606 Approval Name : Signature Date: