ROW2011-00049 APPLICATION FOR
WORK IN RIGHT -OF -WAY (ROW) PERMIT
TIGARD
Development Engineering
13125 SW Hal/ Blvd, Tigard, OR 97223 (503) 639 -4171 FAX (503) 624 -0752
FOR STAFF USE ONLY
General Information: 0
Right -of -Way
Property Address /Location(s): 12215 SW 128th ave 97223 q3( ( ✓ ` Case No.:1) �� ( I 00 ( It
Receipt No.:
Date: -, ( /1(1
*Applicant's Name: COMCAST Application Accepted By: S -MAI
Address: 14200 SW BRIGADOON CT Revised 3/4/09
City /State: BEAVERTON, OR Zip 97 0 0 5
Primary Contact: Sonia Malik REQUIRED SUBMITTAL INFORMATION
Phone: 503 572 9916 Fax:
Contractor's Name: FISK COMMUNICATIONS CONTRACTING Submit a scaled sketch of the
185632 2/24/2011 proposed work to be done
CCB# Expiration:
Address: 6307 NE ST JOHNS RD, STE B
City /State: VANCOUVER, WA. Zi 98661 Professional Engineered Plans are
360 -314 -4454 360- 314 -4456 required for:
Phone: Fax:
• Street Widening
• Subdivision Infrastructure
Plans By: • Main utility line extension:
Address:
City /State: Zip:
Phone: Fax:
Description of work: Directional drill under SW 128th ave. Placing schedule 80
pipe. Serving above address with CAN service line.
Estimated value of work (within the public right -of -way): $ $500.00
Is work related to a LAND -USE DECISION? YES NO X
If so, please specify (MLP, SDR, SUB, etc.) case #:
Is the work related to a BUILDING PERMIT? YES NO X
If so, please specify (BUILDING PERMIT) case #:
*NOTE: Person specified as "Applicant" shall be designated "Permitee" and shall provide
financial assurance for the work.
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Community Development
TIGARD Request for Permit Action
TO: CITY OF TIGARD
Building Division Services Coordinator •
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www. tigard- or.gov
FROM: Owner 1 1 Applicant 1 1 Contractor DQ City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
V CANCEL PERMIT APPLICATION. VOID
REFUND PERMIT FEES (attach receipt, if available). 7A9///
INVOICE FOR FEES DUE (attach case fee schedule and explain below).
1 1 REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: ROW2011 -00049
Site Address or Parcel #:
Project Name:
Subdivision Name: Lot #:
EXPLANATION: Duplicate of ROW2011 -00048 created in error
Signature: 4yAlhi juju Date: 7 / Cj 11 !
Print Name: i e- LL 4
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application.is withdrawn or canceled before any review effort has been expended.
c) not more than 80`%, of the land use application fee for issued permits.
d) not more than 8(T% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80 °% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be retumcd to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
Rte to S s Admin: Date FOR `OFFICE USE ONLY Rte to Admin: Date 7 29Ajill By ,fie
Refund Processed: Date Al A" B %l Invoice Processed: Date B
Permit Canceled: Date ,29j B Iw Parcel Ta: Added: Date B
Receipt # Date Metiod Amount $
I: \Building\ Forms \RecPermitAction.doc Rev 07 /26/07
I I • " Community Development
TIGARD Request for Permit Action
TO: CITY OF TIGARD
Building Division Services Coordinator
13125 SW Hall Blvd., Tigard, OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor [ I City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (■):
Ff CANCEL PERMIT APPLICATION. V O I D
❑ REFUND PERMIT FEES (attach receipt, if available). ,;Z9/// 1-7 INVOICE FOR FEES DUE (attach case fee schedule and explain below).
n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: ROW2011 -00049
Site Address or Parcel #:
Project Name:
Subdivision Name: Lot #:
EXPLANATION: Duplicate of ROW2011 -00048 created in error
Signature: j)Witit Ii Date: 7 I C3 '
Print Name: St4i - L - �lQ
Refund Policy .
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80% of the land use application fee for issued permits.
d) not more than 80% of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80% of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 1 -2 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Adnvn: Date By Rte to I Admui: Date 7 29 // By .r 4 "
Refund Processed: Date AT/9" By • ""- Invoice Processed: Date B
Permit Canceled: Date 7/,z0/ By Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 07/26/07