ROW2012-00013 Community Development
VO
Request for Permit Action 3/26)//
TIGARD
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: f] Owner ❑ Applicant ❑ Contractor /1 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 (1):
• CANCEL PERMIT APPLICATION.
n REFUND PERMIT FEES (attach receipt, if available).
n INVOICE FOR FEES DUE (attach case fee schedule and explain below).
• REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: ROW2012 -00013
Site Address or Parcel #: In front of 14200 -14260 SW 72nd
Project Name: Comcast
Subdivision Name: Lot #:
EXPLANATION: Comcast requests this permit be voided.
Signature: %h,(- Date: 3/20/12
Shir ey Treat
Print Name:
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 S s Admin: Date B Rte t‘ ., Admin: Date-31,a7251 B 4110*-
Iowa
Refund Processed: Date A/ By * ► � _I M Invoice Processed: Date By
Permit Canceled: Date_ yffd//2- By ./ Parcel Tag Added: Date By
Receipt # ^/ /j} Date / Method Amount $
I: \Building \Fo s \RegPermitAction.doc Rev 07 /26/07
V 0 l
III City of Tigard oi
_. Application For Work In The Right -Of -Way
' ROW Permit
FOR STAFF USE ONLY
General Information:
Right- of -Way o0D r3
Property Address /Location(s): 14280 - 14200 SW 72ND Ave Tigard, OR 97224 ,IF: Y Case No.:
project #B27784 Receipt No.: f
Date: �` ( Il
*Applicant's Name: comcast Application Accepted By: c7 T
Address: 9605 SW Nimbus Ave * 2,,_ G%-i
Revised 7/1/10, 3. / i Z . joy
City/State: Beaverton, OR Zip: 97008
Primary Contact: Scott Sarber REQUIRED SUBMITTAL
Phone: (503) 519 -7538 F ax; (503) 605 -6233 INFORMATION
Contractor's Name: Tennessee Cable Service
CCB# ccs# 77450 Expiration: 1O!25/2013 Submit a scaled sketch of the proposed
work to be done
Address: 2310 E. 2nd St.
City/State: Vancouver, WA Zip: 98661
Phone: (390)999 -8900 F ax: (360)696 -9119 Professional Engineered Plans are required
for:
Plans By: K88 • Street Widening
Address: 4120 SE International Way Ste A113
• Subdivision Infrastructure
• Main utility line extension:
City/State: Milwaukie, OR Zip: 97222
Phone: (503) 650 -6041 F ax: (503) 650 -7390
I:curpin \masters \land use applications \row app.docx
Description of work: Directional drill and trench a min. of 36" below grade and install (1 )-2" conduit
Estimated value of work (within the public right -of -way): $ 813.43
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 n NO I.
If so please specify (BUILDING PERMIT) case #:
I *NOTE: Person specified as "Applicant" shall be designated "Permittee" and shall provide financial assurance for the work.
City of Tigard I 13125 SW Hall Blvd., Tigard, OR 97223 I 503 - 718 -2464 I www.tigard - or.gov I Page 1 of 1
■
NOTES:
■
1. ALL WORK AREAS TO BE
RESTORED TO LIKE OR BETTER
CONDITION.
2. ALL OTHER UTILITIES ARE BASED
SW LANDMARK LN 1 OFF EXISTING LOCATES OR UTILITY
STRUCTURES.
3. IT IS THE CONSTRUCTION
CONTRACTORS RESPONSIBILITY
N TO CALL FOR LOCATES BEFORE
DIGGING.
I
4. BORE/DRILL SYM. - 1
� /k E
W
5. TRENCH SYMBOLOGY - —
pl 6. EXISTING CONDUIT -
I , I S
14101 I Z Contact: Scott Sarver
1 ° 'c Title: Fiber Construction Coordinator
D rn Mobile - (503) 519-7538
m ' Office - (503) 605-6311
SW 72ND AVE SW 72ND AVE Email - scott_sarber @cable.comcast.com
DIRECTIONAL BORE DETAIL TRENCH DETAIL 1 I 14140
' •• M• ASPnKT ,�y r' O ./ ?'��. � 6 NOIR TOPSOIL , .. St
• 9605 SW Nimbus Ave
...: .,.. +:x.%05+ 1
-q , t q e� 6 :A ��r.. 1 I Beaverton, OR 97008
N "° q g � g ' sor t p 1
d I • II 55• 1. 4120 SE INTERNATIONAL WAY
:. �. E iE0 . I „. 40' � I SUITE A113
q w != T' • MILWAUKIE, OR 97222
sy • s
VA i . . Email : keengQatl.net DeNgn ey K 6 8 (503) 650.6041
a
.;4 !A �g4 . : I ' SITE ADDRESS:
�T
, T SW 72ND AVE
I 1-2' °°" 0 ! -DI CONDUIT - 0 E 5'FOC TO ROW- -, 1 --5' FOC TO ROW Tigard, OR 97224
10' FOC TO PUE
1 2S 1 W 12N E
21 p'0 REV. DATE DESCRIPTION APPROVED
t2 `22 I 1111411 PERMIT DRAWMG
■
4'X10' BORE PIT 30' DRIVEWAY TO 14200
2 1
.
CO DIRECTIONAL DRILL AP T
AND TRENCH ENCH A MIN. OF 36' BELOW S ONS: PROJECT NUMaEH:
GRADE. (TYPICAL) , 1 24' FROM SEWER 1' = 50' B27784
• �I I � 12' FROM WATER SHEET NUMBER 1111E
1' FROM PUE 14280 /� FIBER ENHANCEMENT
•
1
4' FROM ROW I
j -- 9' FROM FOC PERMIT DRAWING
61 g'25'
I 1 PGE POLE #961 SHEET OF cEE ICI CMME- 692120.5 NAME
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