ROW2011-00067 tw - telecom
Sep-01_11 14:18 503 416 1811
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P.01
SEP 1 2011
CITY OF TIGARD
:--i----_-----:,-.7 BUILDING DIVISION
- liiii: x ' ■ City of Tigard
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-- r--- - -.',' Application for Work in the Right-0f-V(4y Permit
GENERAL INFORMATION ri /. I t,i1.■ I it I 1 --- „,„--- ;,- _-,. _ff-
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9020 SW Washington Square Rd -,1 N 1 !kilt ici :al t j_N- f -----;--‘-
Property Address/Location(s); ----------
_ ,
Bore to take place on SW Hail Blvd, and SW Eliander Ln.
--__ --_ --- — usol tiiiit
—_—___ , _-----------_— _
• Traffic Conical Phut
TW Telecorn (Kevin O'Conner) ____________
'Appileant's Name]
620 SW 6TH. Avenue, Suite 400
Addtcoo: ----------__ _--------
civistotc Pcgtierice_on ____ zip: 07204 _______ 1 igopy„ i 1 -sookAtoki
Dave Miner
Primacy Concoct: It41"f)1)d =i I - 000
, 603-710-6 ---
case th
_._-------- NA'. ----------- itc to ,
1non:
Conttnctor's Nente:113-___-_____________------- Moe: 31
Application Accepted By: --
CCU ti: _________________ Eviration;---_—
agnik40//0///ors
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chy/Stote; ____------- Zip: ________ Afrt flirt ',1-004
Moat: 1 , 2, 0 , / (
p Ion s Br Brian Huddleston
_______ _
Addoir 10860 SW Cit)1EILI112___________ -----------------._
07140
cityistate: SiterWo od, Ore001L__________.—_ .. zip: _ _______
D i To bore NIE Across SW Hall Elvd. to a pole located on the North side oIS‘_AMall Blvd. _
escripton of work
To Bore from same V e location N 2' back of side walk along SW titIllIvil:Ilancler IA, Bore
----
South down eland& Lit on the East side Z East of EOP, Bore West E.i.criancl'i-n. to pcast location.
—. ---_—___ _—_, --
Estimated value of wotk (wIthiti the public tight B ___
is votic minted to 6 LAND-USE DECISION? 0 YES 123 I
i os, please speciP; (Ist1.1 snit, SUN etc) case ft: ...--- ---.
r 2 5-14' 4 V-sat
Is die weak related to o BUILDING PBRIVIIT? 0 ?BS P3
If to, please specify NIA SINR, SUI3, cm) case It ;
Ctly If : 11raf a 1 1312S Sli I tali Illeil.,Tigaril. Ott 91223 I sin: et4 t,74
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Sep -01 -11 14:18 tw telecam 503 416 1811 P.O2
APPLICANTS: To consider an application complete, you will need to submit ALL of the REQUIRED SUBMITTAL ELEMENTS
as described on the front of this application in the "Required S,drnthtal Elements' box.
°P/Cfri31 Person specified as "Applicant" shall be designated " Nerrnittce " and shall provide financial assurance for the work.
'When the owner and the applicant arc different people, the applicant must be the purchaser of record or ti lessee in
possession whit written authorisation frorn the owner or an agent of the owner. The owners) musi sign this application In
the space provided or submit a written authorisation with this application.
BY SIGNING BELOW, THE APPLICANT(8) SHALL anal FY THAI!
• The above request does not violate any decd restrkdons that may be attached to or unposed upon the
subject property.
• If die application is gtanted, 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 in the plot plan, attachments, and exhibits transmitted herewith, arc true;
and the applicants to 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 entice contents of the application, including the policies and criteria,
and Undetgtands the requirements for approving or denying the application.
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App nt Signature Date
. A _�__ __ °J l __
Ow r. ,i . spurt 1)atc
(hvner's Signature Date
Authodxcd Agent's Signature Date
ir...tr5N(1 lki 0 CC; P4c) re___ 4IZ oF vie so$-
Print Name 'fide Phone Number
Signatures of elicit owner of the subject property are required.
t4*g41Aa.uh. L.glhk r tg d.a , t:,�,\ut RV !Sum mmqc a. r r,If
City •f'llg,tnl I 0125 SW FIal IShed., Tig,ud, OR 91221 1 503.716.2464 I www.tigard.nr.gov i Page 2 of 2
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LEGEND:
a CONE OR CHANNELIZING DEVICE
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