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ROW2012-00009 02/09/29112 13:39 5035981960 CITY OF TIGARD PAGE 01/05 J. �. CITY OF TIGARD RIGHT OF WAY PERMIT ft " '` � i - 'xT ' ; COMMUNITY DEVELOPMENT Permit t: ROW2012 -00009 T� Date Issued: 02/09/2012 GA 13125 SW Hall Blvd., Tigard OR 97223 503.718.2421 Parcel: 5E0662 Jurisdiction: TIGARD Site address: Subdivision: Lot: . Project: NW Natural Project Description: In front of SW Dartmouth St.. between SW 72nd Ave and SW 69th Ave.. install 761` of 2' (P) main on SW Dartmouth St. tying in at SW 69th Ave., and headina west by directional bore to SW 70th Ave., then installed in joint trench from stationing 2 +55 to 7+28. See Sketch for details, Contact Lance Cheoley with any quesitons on design at 503- 220 -2427 WOAR00006353 Owner, FEES Description Data Amount ROW Permit Fee 02/09/2012 5300.00 PHONE: Contractor: PHONE: FAX: Applicant: CHRISTINE JEISMANN 220 NW 2ND AVE PORTLAND, OR 97209 PHONE: 503-721-2463 Total S300,00 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 begin?ng work. 7* t Ponn itteelApplicant Signature: . Issued By: AVJA ^". J Special Conditions (See Attached) Note: THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY . s ,, CITY OF TIGARD RIGHT OF WAY PERMIT COMMUNITY DEVELOPMENT Permit #: ROW2012 -00009 13125 SW Hall Blvd Tigard OR 97223 503.718.2421 Date Issued: 02/09/2012 Tj'" . Parcel: SEG862 Jurisdiction: TIGARD Site address: Subdivision: Lot: Project: NW Natural Project Description: In front of SW Dartmouth St., between SW 72nd Ave and SW 69th Ave., install 761' of 2" (P) main on SW Dartmouth St. tying in at SW 69th Ave., and heading west by directional bore to SW 70th Ave., then installed in joint trench from stationing 2 +55 to 7 +28. See Sketch for details. Contact Lance Cheeley with any quesitons on design at 503 - 220 -2427 WO #R00006353 Owner: FEES Description Date Amount ROW Permit Fee 02/09/2012 $300.00 PHONE: Contractor: PHONE: FAX: Applicant: CHRISTINE JEIBMANN 220 NW 2ND AVE PORTLAND, OR 97209 PHONE: 503 - 721 -2463 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 ROW2012 -00009 Type: Condition Name: Status: Severity: ROW 01- CUSTOM CONDITION Applied Notice No restriction of travel lanes is permitted from 7 am to 9 am and 3:30 pm to 6 pm. 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. ROW 16- REPAIRS -LIKE MATERIALS REQ Applied Notice Property disturbed by construction activity shall be seeded with a standard grass mix; shrubs, flowers, barkdust, existing signs, pavement markings, mailboxes, etc., shall be reestablished, reinstalled or replaced, with like kind and material. ROW 17- DRAINAGE CONTROL REQ Applied Notice Effective drainage control is required. Drainage shall be controlled within the work site and shall be so routed that adjacent ' private property, public property and the receiving system is not adversely impacted. The City may, at any time, order corrective action and stoppage of work to accomplish effective drainage control. ROW 18- UTILITIES PRELOCATION REQ Applied Notice Oregon law requires following the rules adopted by the Oregon Utility Notification Center. Said rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0080. Copies of the rules may be obtained from the Center by calling (503) 232 -1987. If you have questions about the rules, contact the Center. NOTE: Damage to utilities shall be corrected at the permit holders expense. ROW 19- UTILITY LOCATIONAL CONFLICT Applied Notice Contractor 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 permit holders expense. Changes must be approved by the City in advance of work performance. Contractor shall coordinate the work with affected utility agencies. ROW 20- TRENCH - PATCH /SAFETY /LBILITY Applied Notice A temporary hard - surface patch (Cold mix A.C. or Hot mix A.C. base paving) shall be placed on trenches within roadways at the end of each day's work. No trench, on site or off site, shall be left at any time in an unsafe condition. The permit holder is responsible for and is liable for hazards or damage resulting from the work. ROW 21- REPAIRS REQ - INSPTR OPINION Applied Notice Work provided for under the permit shall include repair of existing facilities (roads, ditches, etc.) as may be necessary, in the City Inspectors opinion, to overcome deterioration or damage which occurred in conjunction with the work authorized by the permit. Corrective work shall be done at the permit holders expense. ROW 22 -AS- BUILT /ENGR CERTIF REQ Applied Notice At the end of each year, or an a mutually agreeable yearly date, any entity making changes to its facilities in the public right -of -way shall submit complete "as- built" drawings 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 engineers certification of installation compliance (form attached). ROW 23 -DAILY INSP REPORTS REQ Applied Notice The permit holders Engineer /Inspector shall submit daily inspection reports, on a weekly basis, to the City's Inspector. (see Developer- Engineer Agreement note #5). ROW 24- TESTS /REPTS TO VALIDT CLMS Applied Notice The City's Inspector may, at their discretion, require provision of tests and or reports from the permit holder, permit holder's engineer or contractor to validate claims of material or construction adequacy /compliance. Such tests /reports shall be provided at the permit holder's expense. ROW 25- RELEASE - WAIVER REQ Applied Notice The permit holder shall provide a copy of a properly executed Release & Waiver document to the City for each ownership disturbed by construction activity, as evidence of disturbance resolution and owner satisfaction. ROW 26- MONUMENT PROTECTION REQ Applied Notice Existing monuments, property corners, and survey markers shall be protected. Replacement shall be at the permit holders expense. ROW 27 -PROB SOLVING - RESPON PARTY Applied Notice The permit holder shall 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 an emergency. The permit holder shall notify the City Inspector, in writing, of any /all assignment changes. ROW 28- CONSTR SAFETY - RESPON PARTY Applied Notice The permit holder shall cause his contractor to provide to the City Inspector, in writing, the name and 24 hr emergency telephone number of a designated "Competent Person" responsible for construction safety as per OR -OSHA, Chap. 437, Div. 3 Construction, Subdivision P - Excavations. The contractor shall notify the City Inspector of any /all assignment changes. ROW 29- ESMT /RT OF ENTRY - RESPON Applied Notice It is the sole responsibility of the permit holder to provide for 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 permit holder's failure to obtain or provide for proof of right -of -entry or easements. CITY OF TIGARD RECEIPT 5 a. 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 185487 - 02/09/2012 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID ROW2012 -00009 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 02/09/2012 $300.00 Payor: NW Natural Total Payments: $300.00 Balance Due: $0.00 • Page 1 of 1 APPLICATION FOR WORK IN RIGHT-OF-WAY (ROW) PERMIT • : ° Development Engineering TIGARD 13125 Sit' Hail Blvd- Tigard, OR 97223 (503) 639-4171 1-AX: (503) 624 -0752 FOR STAFF USE ONLY General Information: Right of - - �� 0060 / Property AddresslLocation(s) Dartmouth St Case No.: : !1(( E/L!/ between SW 72nd Ave and SW 69th Ave. See sketch attached. Receipt No.: /k 5 -- io Date: 141 7 Natural Application Accepted By: S "Applicant's Name: NW Nt l � ��'�� lioi ,d 34, /�Q 09 i g ` Z ,� Address: NW 2nd Ave '• 2 city /state:Portland OR Zip .97209 Primary Contact: Christine Jeibmanr, REQUIRED SUBMITTAL INFORMATION Phone: 721 -2463 Fax: 503 -273 -4822 Contractor's Name : same as applicant 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 NW Natural • Subdivision Infrastructure Plans By: • Main utility line extension: Address: NW 2nd Ave City /State: Portland OR Zip: Phone: 721 -2463 Fax: (503) 273-4822 Description of workanstall 761' of 2 "(P) main on SW Dartmouth St tying in at SW 69th Ave and heading west by directional bore to SW 70th Ave then installed in joint trench from stationing 2 +55 to 7 +28. See sketch for details. Contact Lance Cheeley with any questions on design at (503) 220 -2427 Estimated value of work (within the public right -of -way): $1902.50 Is work related to a LAND -USE DECISION? YES 1 I NO If so, please specify (MLP, SDR, SUB, etc.) case #: Is the work related to a BUILDING PERMIT? YES I I 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. 24" and services must have a minimum depth of IS" S L unless there is an approved va riance. 4. All transmission lines must have a minimum depth of H 30" in Class 'V locations and 36" in Class '2, 3, & 4' o locations, unless there is an approved variance. I- -- 335' #11990 5. Written dimensions on this construction sketch 0 have precedence over scaled dimensions. N 1"(P) (W) 6. Pressure test shall be tested in accordance with 61' #11 s standards in CFM and Engineering Standard Practice. ( 7. Test medium for class "B" main shall be air, unless otherwise noted. Test medium for class "C -F" main shall be water, unless otherwise noted. S. For Class C or higher tests, see Design Document and Hydrostatic Report. SW DARTMOUTH STREET 2 "(P1 /JT • f ' r INSTALL: BLDG. A N _ =N LW BLDG. B N 8 ' ❑ 1# Anode w _= Q It drawing ) ; 302' 294' #12105 W) 274' Initial -- Q #12120 BLDG. C z (77) N ti 11' R. PM PM IP NOP ACTIVITY # ORDER # 45 710 03353781 0 50 100 Feet 1 in = 100 ft ITATE DESIGNED RSP DATE 12/10/2011 OR DRAWN KDC DATE 02/02/2012 An /An inA ,- - -As required in Off typical sections Street Street of construction 1 ---4_ -j _.__. _._.__......_... --I plans i A M 1' T —cut (see Surfacing jjj , note 1) Topsoil or as ,,,� / directed -- - - - - -- Base Material - o a) 0 - �o 0 I ! O cL a U In � I I v+' Ala) _v , \__ UI h -'1 co . a) U 00 0 >, z' o /'`.. • : 1 C - - o a £ a) 0 .. a O a) a) Q r, = i•- N I L- . N a) ' a (n a) f • > i k- O , L. O . Q jo -: . —,,o U 6" Min bedding 6 ,, X' 6 below outside of _.,.__._ .�. - _..... _ �-. pipe bell 3 4 — 0" MIN ' MIN �— P " P / crushed aggregate ,/ ,r� �T 2 Min Trench ,- \ .: < % \' ,,,-� ✓ -'`` foundation ,< stabilization if required ------- NOTE: 1. 1' T —CUT FOR PIPE ONLY PROJECTS. 2. JOINTS TO BE TACK AND SANDED. 3. SAWCUT SHALL BE TACK COATED WITH BITUMINUS ASPHALT EMULSION. CPI'1 ()P'11G,1R17 APPROVED BY: NO SCALE RI'Gc N THEODORE S. KYLE, P.E. TRENCH ENGINEERING DIVISION U. PUBLIC WORKS DEPARTMENT CITY ENGINEER DWG. NO. TIGARD, S.W. HALL BLVD. ARD, OREGON 97223 JANUARY 2011 1 8 0 TIG B A C K F I L L TIGARD VOICE: (503) 639 -4171 FAX: (503) 684 -7297 APPROVAL DATE 0£�0 JL TO 8£TV'039£TVTO Z9 •f • VTOSS O *To Z6OVTO ] £60VTO TO = ]S TT09£ N06O 10 lT ?95t'TTO9£ L£009£SS EMIT 11 b1TO9£ LE6TT SZ6TT 6T6TT 0E6TT 69 391109 986TT 1L6TT 89611 L9T A789TVTO r 3 0 Z 36Zt09£ 8b009£SS 69TVTO EZOZT 78ZTO9$$ESS MatI9E STTZT SOOZT LTOZT TTOZT SZOZT St'6TT St 6T T t6 TT S16TT S16 TT Stt61T IS HI f0Wlab Tb OVTOSS 861VT t6 TT St76TT S16 TT S1'6TT t6 TT Stt6TT t6 TT Str6TT S16TT S16TT 3990VTO 7161 VT0 SEOZT 8'v I 0 3101VTO 3980VT