ROW2011-00057 08/16/2011 12:42 FAX 503 273 4822 NW NATURAL ENG 002
es/15/2011 11:11 5635981SSQ CITY OF TIGARD PAGE 06/10
., C IT TIG Ikr RD RIGHT OF WAY PERMIT
COMMUNITY DEVELOPMENT
,.,..:,,: PMENT Permit ; ROW2011 -00057
,T k'r4r? 13125 SW Hall Blvd„ Tigard OR 97223 503.718.2421 Date Issued: 0$11612011
Parcel: 88(31 013
Jurisdiction_ TIGARD
Site address:
subdivision:
Lot;
Project NW Natural
Project Description: In front of 13724 SW Walnut Ln„ emergency damage to main. Replaced 2ft of 2" poly main due to
damage by customer. Two holes dug t4 shut off gas 1ft in ROW. Type of surface unknown. Completed
7/24 WO#3348263
Dwhot;
FEES
Description Date
Amount
PHONE: ROW Penni Fee 08118/2011 5300.50
Contractor:
PHONE:
FAX:
Applicant:
PATTY HOUSE
220 NW 2ND AVE
POR rLAND, OR 97209
PHONE: 503 -226 -4211
Total $300.00
Please sign below to indicate acoeptsnce of conditions and return a copy with the proposed work schedule along with names and contact
information of responsible parties before beginning work.
Permtttee /Applicant r
Signature: x/11 i% /
Issued By;
Special Conditions (See Attached,
Note: THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
•
CITY OF TIGARD RIGHT OF WAY PERMIT
11111 1. COMMUNITY DEVELOPMENT Permit #: ROW2011 -00057
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2421 Date Issued: 08/16/2011
Parcel: SEG1013
Jurisdiction: TIGARD
Site address:
Subdivision: Lot:
Project: NW Natural
Project Description: In front of 13724 SW Walnut Ln., emergency damage to main. Replaced 2ft of 2" poly main due to
damage by customer. Two holes dug to shut off gas 1ft in ROW. Type of surface unknown. Completed
7/24 WO #3348263
•
Owner: FEES
Description Date Amount
ROW Permit Fee 08/16/2011 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
PATTY HOUSE
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:
Issued By:
Special Conditions (See Attached)
Note: THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for ROW2011 -00057
Type: Condition Name: Status: Severity:
ROW 01- CUSTOM CONDITION Applied Notice
<Custom Condition goes here>
ROW 02- PERMIT & PLAN REQ ON SITE Applied Notice
A copy of the permit and all attachments, and a copy of the approved construction plan and all amendments shall be
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 the aforesaid must be approved by the City, in advance of work performance.
ROW 03 -TRAF CTRL - SPECIF (CITY) Applied Notice
The City's standard specification for traffic control is "Manual on Uniform Traffic Control Devices for Streets and Highways ",
U.S. Dept. of Transportation, F.H.A., 1988 Ed.
ROW 04 -TRAF CTRL -CONTR RESPON FOR Applied Notice
Traffic control shall be provided for by the contractor in accordance with the City's standard specification and, also, in
accordance with a City (job specific) approved traffic control plan. A copy of the approved traffic control plan shall be
available at the work area.
ROW 05 -TRAF CTRL -ROAD CLOSURE Applied Notice
Public roadway shall not be closed to traffic, at any time, without having first obtained written approval from the City
Engineer. The permit holder is responsible for provision of timely notification of traffic flow disruptions to area wide
Emergency Services (Tigard Police Dept., Tualatin Fire & Rescue) and to Tri -Met and Tigard School District.
ROW 06 -TRAF CTRL - ADVANCE WARNING Applied Notice
Advance warning of imminent traffic disruption shall be provided to the general motoring public by placement of an advance
notification sign at each end of the construction area 72 hours (min.) before initiation of construction work.
ROW 07 -TRAF CTRL -PRIV PROP ACCESS Applied Notice
Access to existing properties shall be maintained at all times, including normal delivery service and mail service and if not,
shall be cause for work stoppage until effective access is established.
ROW 08 -TRAF CTRL - DEVICES IN PLACE Applied Notice
Traffic control devices, flagpersons, etc., shall be in place prior to initiation of construction work and shall be effectively
maintained.
ROW 09 -TRAF /NOISE CTRL -WORK HRS Applied Notice
No work will'be permitted during the hours of darkness, nor between 9:00 p.m. to 7:00 a.m. Monday through Friday, nor
between 9:00 p.m. to 8:00 a.m. Saturday, nor between 9:00 p.m. to 9:00 a.m. Sunday.
ROW 10 -TRAF CTRL -MIN LANE WIDTH Applied Notice
Minimum travel lane width shall be eleven (11) feet; pedestrian travel shall also be provided for.
ROW 11 -TRAF CTRL -CITY CAN MODIFY Applied Notice
The City reserves the right to add to or modify traffic control requirements as may be necessary to effectively control traffic
and to assure public safety.
ROW 12 -INSP 24 HR NOTICE REQUIRED Applied Notice
The permit holder or his contractor shall notify the City's inspector Zen Dutson, at 503- 718 -2472 or email at
zen @tigard- or.gov, twenty -four (24) hours prior to commencing work, twenty -four (24) hours prior to any staged inspection,
and after completing work covered by the permit.
ROW 13- HAZARDS -CERT OF INS Applied Notice
Maintenance of the work area and approach roads is the responsibility of the permit holder. The work area and approach
roads shall be maintained in a clean condition, free from obstructions and hazards. A copy of the permit holders Certificate
of Insurance shall be available at the work area.
ROW 14- DEBRIS - MATERIALS Applied Notice
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
cleanup and stoppage of work to accomplish cleanup.
ROW 15- EROSION CTRL REQ Applied Notice
Effective erosion control is required. Erosion control devices must be installed and maintained meeting D.E.Q.
requirements. The City may at any time order corrective action and stoppage of work to accomplish effective erosion
control.
Applied Notice
grass mix; shrubs, flowers, barkdust, existing
ROW 16-REPAIRS MATERIALS all be seeded deO l sh with like kind and barkdust,
material. xt 74
Property disturbed etc., shall be reestablished, reinstalled or rep Notice
Prop Y bed by construction activity shall be seeded with a standard g
signs, pavement markings mailboxes, Applied scent
17- DRAINAGE CONTROL REQ impacted. The City may, at any time, order
ROW d. Drainage shall be controlled within thelwork site and shall be so routed that adjacent
Effective drainage control is require system is not adversely P
public property and the receiving lish effective drainage control. Notice
corrective property, ac io P a e of work to accomp Applied
corrective action and stopp 9
ROW 18- UTILITIES P s adopt TION REQ calling (503) 232 1987.
the rules adopted by the Oregon Utility Notification obtained from the Center rules are set forth in O
Oregon law requires following th Copies of the rules may b
er holders
If you have questions e OAR the rules, contact Cop
uestions about the rules, contact the Center. NOTE: Damage to utilities shall be corrected at e P
If you have q lied Notice
expense. App
(pothole
prior to start of work (p
ROW 19 UTILITY LOCA for both CONFLICT it shall be done at
performance. Contractor shall
Should conflicts arise and redesign or relocation of facilities be necessary,
Contractor must verify all existing utilities for both vertical elevation and horizontal location p
before m t holders if ne expense. S roved by the City in advance of work
the permit holders expense. Changes must be approved
20- TRENCH - PATCH /SAF /LBILITY P Notice
coordinate the work with affected utility age ncies. applied
paving) shall be placed on trenches within Notice
roadways
ROW oadw
A temporary hard - surface patch (Cold mix A.C. or Hot mix A.C. base p 9 time in an unsafe condition. The p
at the end of each day's work. No trench, on site or off site,e h esu b lt rag from the work.
responsible for and is liable for hazards or damage applied Notice
holder is resp in the
ROW 21- REPAIRS REQ- INSPTR OPINION etc.) as may be necessary,
Work provided for under the permit shall include repair of exi t hich cilities ( datl , dit hes, with the work authorized by the
e City Inspectors opinion, to overcome deterioration or damag
permit. Corrective work shall be done at the permit holders expense.
Notice
Applied
entity making changes tp its facilities in the public
ROW 22 or an a mutually CERTIF REQ n th eip u made to
right-of-way the end of each year, or an a mutually agreeable s showing ing all new public improvements, including any Y
complete "as- built" drawings showing any system or
Y
right -of -way shall submit comp
the previously ep provided to the C plans and, also, any improvement which may impact an existing p
facility, shall be provided to the City by a registered civil engineer along with an engineers certification of installation
Notice
compliance (form attached). applied
ROW 23 -DAILY INSP REPORTS REQ
The ermit holders Engineer /Inspector shall submit daily inspection reports, on a weekly basis, to the City's Inspector. (see
P
Developer- Engineer Agreement note #5).
Applied Notice
ROW 24- TESTS /REPTS TO VALIDT CLMS om The City's Inspector may, at their discretion, require provision suofi ad an d or reports o p fr o et e ph t mi t h o lde rt emit ho lder s
engineer or contractor to validate claims of material or
provided at the permit holder's expense. Applied Notice
The permit
ROW 25- RELEASE - WAIVER REQ
of a properly executed Release & Waiver document to the City for each ownership
,
disturbeed d by y construction shall provide truction activitt y, copy P as evidence of disturbance resolution and owner satisfacApplied Notice
ROW 26- MONUMENT PROTECTION REQ
Existing monuments, property corners, and survey markers shall be protected. Replacement shall be at the permit holders
expense. Applied Notice
ROW 27 -PROB SOLVING- RESPON PARTY
The permit holder shall provide to the City Inspector, lems, take active action and, in general, will be responsible number
n case of an
(2) persons who have authority to resolve prob
emergency. The,permit holder shall notify the City Inspector, in writing, of any /all assignment pplied es Notice
ROW 28- CONSTR SAFETY- RESPON PARTY the name and 24 hr emer
etent Person" responsible for construction safety as per OR -OSHA, Chap. 437,
Div. 3 C
The permit holder shall cause his contractor to provide to the City Inspector, in writing,
telephone number a designated "Comp
Div. 3 Construction, Subdivision P - Excavations. The contractor shall notify the City Inspector of any /all assignment
, changes.
Applied Notice
ROW 29- ESMT /RT OF ENTRY- RESPON
is the sole responsibility the permit holder
ed easements shall be provided to the City. The City shall in no way be
r' It Proof construed
Proof f of right -of -entry, or properly executed or easements.
to be liable for the permit holder's failure to obtain or provide for proof of right-of-entry
RECEIVED
AUG 0 2 2011
APPLICATION FOR 77 �� a
WORK IN RIGHT -OF -WAY (ROW ) PI !NG
Development Engineering TIGARD
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 FAX: (503) 624 -0752
FOR STAFF USE ONLY
General Information:
Right -of -Wa
Property Address /Location(s): 13724 SW Walnut Ln Case No.: 44.11 - Ol o0
wo #3348263 - , Receipt No.: a 3(p loc
Date: (9a /
*Applicant's Name: Natural Application Accepted By: S - 4 �
��yp s
220 NW 2 n d A v Revised 3/4/09+, O � ' / 37 / / 36 6 Address: ..�P
City /State: Portland OR Zip : 97209
Primary Contact: Patty House REQUIRED SUBMITTAL INFORMATION
Phone: 226 -4211 X 4331 Fax: 503- 273 -4822
Contractor's Name: Submit a scaled sketch of the
proposed work to be done
CCB# Expiration:
Address:
City /State: Zip: Professional Engineered Plans are
required for:
Phone: Fax:
• Street Widening
NWN • Subdivision Infrastructure
Plans By: • Main utility line extension:
Address:
City /State: Zip:
Phone: Fax:
Description of work: Emergency damage to main.
replaced 2ft of 2" poly main due to damage by customer. Two holes dug to shut off gas 1ft in ROW. Type of surface
unknown. completed 7/24
Estimated value of work (within the public right -of -way): $
Is work related to a LAND -USE DECISION? YES NO
If so, please specify (MLP, SDR, SUB, etc.) case #:
Is the work related to a BUILDING PERMIT? YES NO
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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NW Natural PLAT: 1- 043 -015 COUNTY: WASHINGTON - 08/02/11 12:59
(503)226 -4211 TOWNSHIP: TO2S RANGE: R01 W SECTION: 4NW SCALE: 1 IN = 100 FT USER ID: peh
CITY OF TIGARD RECEIPT
g .., 13125 SW Hall Blvd., Tigard OR 97223
• 503.639.4171
TIGARD
Receipt Number: 183666 - 08/16/2011
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ROW2011 -00057 ROW Permit Fee 100- 0000 -43114 $300.00
Total: $300.00
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Trust Account NWNDEP STREAT 08/16/2011 $300.00
Payor: NW Natural
Total Payments: $300.00
Balance Due: $0.00
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