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PFI2020-00079
CITY OF TIGARD PUBLIC FACILITIES IMPROVEMENT PERMIT • s COMMUNITY DEVELOPMENT Permit#: PF12020-00079 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 03/06/2020 Parcel: 2S 103A D03900 Jurisdiction: Tigard Site address: 13060 SW 107TH CT Subdivision: PATHFINDER Lot: 29 Project: Hughes Sewer Project Description: Replace sewer line from property to city connection in ROW. Class of Work: FEES Description Date Amount Type 2-Sidewalk/Driveway Approach PFI Permit Fee 03/06/2020 $300.00 Total $300.00 Owner: REQUIRED INSPECTIONS Call 503-639-4175 for the IVR inspection request line or visit the City of PHONE: Tigard website at www.tigard-or.gov to schedule inspections online. Contractor: NORTHWEST CONCEPTS& EXCAVATION 17242 S CARUS RD BEAVERCREEK,OR 97004 PHONE: 5036323400 Applicant: HANNAH PARTRIDGE PO BOX 1707 CLACKAMAS, OR 97015 PHONE: 5038822104 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: — 1✓ti— Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for PF12020-00079 Type: Condition Name: Status: severity: PFI_Sidewalk/[ 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_Sidewalk/[ 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 dean-up. PFI—Sidewalk/1 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_Sidewalk/[ 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—Sidewalk/1 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_Sidewalk/[ 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_Sidewalk/[ 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 dosure. PFI_Sidewalk/[ 08-TRAFFIC CONTROL ADVANCE WARNING Applied Notice Advance warning of traffic disruption shall be provided to the public by placement of an approved advance notification sign at each end of the construction area 72 hours(min.)before initiation of construction work. PFI—Sidewalk/1 09-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_Sidewalk/[ 10-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_Sidewalk/[ 11 -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_Sidewalk/[ 12-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—Sidewalk/1 13-DRAINAGE CONTROL Applied Notice Drainage shall be controlled within the work site and shall not adversely affect adjacent private property,public property and the receiving system. The City may at any time order corrective action and suspension of work to accomplish effective drainage control. PFI_Sidewalk/[ 14-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_Sidewalk/[ 15-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_Sidewalk/[ 16-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_Sidewalk/[ 17-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_Sidewalk/[ 18-SEWER SYSTEM TEST Applied Notice A sewer system air-test and/or DVD T.V.test report and one set of"As-Builts"shall be provided for review and approval. PFI—Sidewalk/1 19-PRECONSTRUCTION MEETING Applied Notice Before initiating any construction activity,the applicant shall coordinate with the City's inspector,Trent Brickey at 503858-2051,to establish a preconstruction meeting. PFI_Sidewalk/[ 20-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. PFI—Sidewalk/1 21 -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_Sidewalk/[ 22-DAILY INSPECTION REPORTS Applied Notice Applicant shall submit daily inspection reports,on a weekly basis,to the City's Inspector. PFI—Sidewalk/1 23-MONUMENT PROTECTION Applied Notice Existing monuments, property comers,and survey markers shall be protected. Replacement shall be at the permit holder's expense. PFI_Sidewalk/[ 24-VALIDATION OF MATERIAL/CONSTRUCTION Applied Notice The City's Inspector may, at his discretion, require tests and or reports from the applicant to validate claims of material or construction adequacy/compliance. Such tests/reports shall be provided at the applicant's expense. PFI—Sidewalk/1 25-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—Sidewalk/1 26-RIGHT OF ENTRY/EASEMENTS Applied Notice Applicant to obtain proper right-of-entry and/or easements prior to starting work. Proof of right-of-entry or properly executed easements,shall be provided to the City. The City shall in no way be construed to be liable for the applicant's failure to obtain or provide for proof of right-of-entry or easements. PFI—Sidewalk/1 27-PRIVATE PROPERTY AGREEMENTS Applied Notice Provide the City a copy of an executed agreement[s]from the owner for each private property disturbed by construction activity. PFI—Sidewalk/1 28-AS-BUILT DRAWING Applied Notice One as-built drawing showing all new public improvements, including any revision made to the previously approved construction plans and,also,any improvement which may impact an existing public system or facility,shall be provided to the City by a registered civil engineer along with an engineer's certification of installation compliance(Certificate of Compliance). PFI_Sidewalk/[ 31 -OTHER Applied Notice Other RECEIVED City of Tigard MAR Of 2020 CITY OF IGARD PFI 000r1 et s ENGINEERING DEPARTMEIMNNING/ENGINEERING Public Facilities Improvement (PFI) Permit PROJECT INFORMATION t ' {1. OF WORK Project name: Sin, 67 ❑ TYPE 1–Franchise Utility Work Brief description of project performed by PGE, or utility agency CA A TYPE 2–ROW Sidewalk/Driveway/Sewer �— Work performed for the purpose of.. • Sidewalk installation or repair • Driveway approach installation and repair SITE INFORMATION • Sanitary sewer lateral installation and Location (address if available): �5 (nQ 1 n7 t'Y t main line tap ❑ TYPE 3–Full Scale Development Work performed with land use approval which includes any 4 the following: • Subdivisions or Partitions APPLICANT INFORMATION • Strcetwide4ing 1 Name: O • Mainline in talladon for sanitary sewer, storm sewer, Tigard ware, and Tigard Mailing address: & k rea water service a City/State: C�Arel�G�© I (Z zip:On 01� ❑ TYPE 4–Small Cell Technology Phone: S l.Z� s� �t oOLA "'t' 13 TYPE 5–Tigard Triangle }�- Email:k� �11A A�plFt�t'vl'� IPhone: NOTE: Type 1 pard 2 applications maybe Contact nam;J,,))e: (1� k Owl emailed to rrns rthirsratipar�or�o�. Phone: Email: CONTRACTOR INFORMATION ❑ Same as applicant Name: �i U Q CVn,-0r,,tA CCB Number. Mailing address: AQ a o, City/State: UA tnyf7 r4-e q Gip Phone:�`2e i Email: k J M( 01-5--�!'A ub h f t� ��, • �,,� ENGINEER INFORMATION Name: Mailing address: City/State: Zip: Phone: Email: ADDITIONAL INFORMATION Estimated value of work is required(if over$5,000):$ Ck O (within the public right-of-way) Is work related to a LAND USE DECISION? ❑Yes A3:No Case number: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • wwwdgmxl-orgov 503-718-2421 • Page 1 of 4 s Vicinity Map 8aaver7on ' _MapTitle Tlgar d City of Tigard, Oregon iSanitary Manhole Tua la'N • Miss.. la NW CM.Dvc[pn C Abam TeO Sanitary Glow Arrows In Sernn SS03AO25 10 Sanitary Main ` — M 5ervue 7 New COMNuaiOfl \\ .• ae.rteonea 6//C O�� Unimproved Right of Way -''�- --- •• Proposed Trails -- Proposed Streets coYeaw neyneornooa Route Re� f, •• nelanDorlxodRwtelOuulde '�••" Martian,Meal Proposed PRV —_ Proposed Water Structures T i g r ■ PumP U.11en 13000 Proposed Water Pipelines &7- alp Pl Watn Mams 550 PI Warer Mal, N/ QQ ExistingPum Stations 01 b5 130" ■ Proposed Sewer Pump StationV ` -LJ Future Sewer Pump Station f URA �' ' ► Proposed Sewer Trunk Line Al a Proposed Sewer Force Mains Pump Station Service Areas staIale _ 13 PwPosco —a - a FUTURE t'. ♦ Flow Splitter Device Dara is aarbae Ice...,aa.a.raa..Tea cur of Tigard sale....x.axr.ro.xe.uu«.x noaeraa a.la u.s..We'--.a.'say.uwaum x..eNau....eI.q al l..uu px1aJ Uub.l0.Cllr.1 TIPra.hall ea II.eam'Ix..1 a.rx...wi.x....or Ia.xxavlx 1.la.,a1e.w.11.n Pr.vlF.a r.Palal..f el Scale 0.01 PANG City of Tigard - --_- - - - - 13125 SW Hall Blvd 0 Tigard, On 97223 Map Created: (503) 639-4171 022412020 www.tigafd-or.gov 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 15.04.140. * With the exception of a utility operating pursuant to a valid franchise or license 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 must sign this application in the space provided or submit a written authorisation with this application. Franchised or licensed Utilities are not required to ohtain the owner's signature on the application. I,the applicant,certify that: • To the best of my knowledge, all the information provided within this application package is complete and accurate. • The above request does not violate any recorded deed restrictions that may be attached to or imposed upon the subject property. • If the application is granted,I will exercise the rights granted in accordance with the terms and subject to all the conditions and limitations of the approval. Ap' a or d agent's signature Print name Date Property owner's signature (if required) Print name Date C#se No:M20?!� � Peru fee: 3�,otq Received by- Date:W�12-4 Aproved by: %i'ef4le Date; 3/5—I20ZU Notified by Date: City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 2 of 4 --ommeN NORT-27 OF ID: MC ,d►coRa CERTIFICATE OF LIABILITY INSURANCE DATE(MMIY) �� 3!05/2002020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Craig Sopke Premier NW Insurance ---- 421 High St#200 P No E>d:503-655.6344 N,;50355-2035 Oregon City,OR 97045 ADDRESS:Craig Sopke SS:CBopke remiernw.net INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:United Fire Group /058589 INSURED Northwest Concepts& INSURERB:SAIF Corp36196 Excavation LLC 17242 S. Carus Road INSURER C:Western Surety Company 13188 Beavercreek, OR 97004 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRR TYPE OF INSURANCE INSD POLICY NUMBER MMIDONYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE OCCUR X 60515274 04/16/2019 04/16/2020 PREMISES Ea occurrence $ 100,00 MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY [71LOC 2,000,00PRO X OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Es accident AWAUTO BODILY INJURY(Per person) $ ASH LLOWNEDAUTOOSDULED I BODILY INJURY(Per axident) $ HIRED AUTOS NON PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA DAB X OCCUR EACHOCCURRENCE $ 1,000,00 A E.L. CIDENT X EXCESS UAB CLAIMS-MADE 60515274 06/18/201910411612020 AGGREGATE $ 1,000,00 DED RETENTION$ $ WORKERS COMPENSATION XPER AND EMPLOYERS'DABIDrTY STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 866296 11/01/2019 1110112020 EACH $ 500,00 OFFICER/MEMBER EXCLUDED? NIA - - (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS bel I E.L.DISEASE-POLICY LIMIT $ 500,00 C Contractor Bond 62960738 10/3112019 10/31/2020 OR Resid 20,00 C Contractor Band 62901428 09/02/2019 09/02/2020 OR Comm 75,00 DESCRIPTION OF OPERATIONS/LOCATIONS)VEHICLES (ACORD 101,Additimwl Remarks Schedule,may bealtocMd Xnlore apace Is required) Certificate holder(s) are additional insured as respects their interest in the operations of the named insured subject to policy conditions, limitations&exclusions. CERTIFICATE HOLDER CANCELLATION Ci of Tigard SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City o SW Hall BLVD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tigard,OR all B ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORRIIZZ•EED_RREQ—PRR9E_SEN�TATIIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD