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ROW2012-00057 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT ■ q Request Perm Act q /O L// L l , , 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov TO: CITY OF TIGARD Building Division Services Supervisor 13125 SW Hall Blvd., Tigard, OR 97223 Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov FROM: ❑ Owner ❑ Applicant ❑ Contractor 1kCity Staff (check one) REFUND OR Name: P i- INVOICE TO: (Business or Individual) 6 Mailing Address: City/State /Zip: Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1): CANCEL /VOID PERMIT APPLICATION. El REFUND PERMIT FEES (attach copy of original receipt and provide explanation below). ❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below). ❑ REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit). Permit #: 1 ti ) /Z —7Q Site Address or Parcel #: Project Name: Subdivision Name: Lot #: EXPLANATION: ��j 6 9/3- � l Y- e /Pf-t t /D. D 'tea- - - �7T ‘ S4 i I) s1J signature: L� Date: 9'2. S 12 Print Name: W -'S 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 b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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 2 -4 weeks for processing refunds. Rte to Sys Admin: Date By Rte to")3 Admin: Date /0/2//1— By Refund Processed: Date A/ ,9- By Invoice Processed: Date By Permit Canceled: Date /e /ZS . By arcel Tag Added: Date By Receipt # Date Method Amount $ I:\ Building \Forms \RegPermitAction.doc Rev 05/25/2012 117 CITY OF TIGARD RIGHT OF WAY PERMIT COMMUNITY DEVELOPMENT Permit #: ROW2012 -00057 1 3125 SW Hall Blvd., Tigard OR 97223 503.718.2421 Date Issued: 06/21/2012 TIGARD Parcel: SEG819 Jurisdiction: Site address: SW Subdivision: Lot: Project: Portland General Electric Project Description: In front of 9430 SW Center St. replacement of 2 anchors, install transformer Owner: FEES Description Date Amount ROW Permit Fee 06/18/2012 $300.00 PHONE: Contractor: PHONE: FAX: Applicant: RALPH REISBECH 9480 SS BOECKMAN ROAD WILSONVILLE, OR 97070 PHONE: 503 - 570 -4409 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: ` /4611/4 AA i/ Issued By: / °t Special Conditions (See Attached) Note: THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for ROW2012 -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 <name >, at <phone #> or email at <email address >, 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. Jun. 18. 2012 3:50PM PGE WLC No. 3214 P. 3 ' RECEIVED ©O APPL JUN l a (CATION FOR a I�IioRK IN RIGWT -OF -WAY (ROW) PERMIT 111 cr� OFT A NIi D �eve lopme nt Engineerin T I C A tD 9 13125 SW Nall Blvd_, Tigard, OR 97223 (503) 639 -4171 FAX: (503) 624 -0752 FOR STAFF USE ONLY General Information: WR 678565 'if Right -of -Way Property Address/LocatIon(s): 9430 SW CENTER ST Case No.: /K O1ll.2. 0 /4-0670/ 7 Receipt No.: f t 7,165 *Applicant's Name: Portland General Electric Date: 6 -42. Address: 9480 SW Boeckman Rd " " " " " " „ "`�° " " " "' "'' °"' r REQUIRED SUBMITTAL INFORMATION I City /State: Wilsonville OR Zip: 97070 i 9.7 2 &hg t +6 Primary Contact: RALPH REISBECK memx e Phone: (503) 570.4409 Fax: (503) 570 -4420 Submit a scaled led sketch of the proposed work to be done Contractor's Name: N/A CCB# Expiration: _ Professional Engineered Plans are Address: _ required for: city /State: Zip' • Street Widening Phone: Fax: • Subdivision Infrastructure • Main utility line extension: Plans By: Address: City /State: _ Zip; _ Phone: _ Fax: Description of work: PGE TO REPLACE 2 ANCHORS, INSTALL TRANSFORMER _ Estimated value of work (within the public right -of -way): $ Is work related to a LAND -USE DECISION? YES I 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. '. 6 .p.m. �0,... tigard permitslwr 678565 city of tigard permit.docx a 1 P kt y�Alwn lU V G I �vvv ` l TRANSMISSION VERIFICATION REPORT TIME : 06/21/2012 13:13 NAME : FAX TEL SER.# : 000G7J417785 DATE,TIME 06/21 13:13 FAX NO. /NAME 5035704420 DURATION 00:00:00 PAGE(S) 00 RESULT BUSY MODE STANDARD BUSY: BUSY /NO RESPONSE Q1 121 Jun. 18. 2012 3:50PM PGE WLC No. 3214 P. 1 Portland General Electric Wilsonville W Line ckma n Center 9 Road 80 S Boeckma Road Wilsonville, OR 97070 FAX COVER SHEET DATE; TO / A N: Lo ■.?•z k. Oc Q7, carte` _ -- • AT: • RECEIVER'S PHONE NO.; RECEIVER'S FAX NO.; FROM; r LCD \. SENDER'S PHONE NO.: SENDER'S FAX NO.: 503 - 570.4420 4AD NUMBER OF PAGES (Including cover sheet): 3 REGARDING; • CONFIDENTIALITY NOTICE This facsimile transmission (and all documents accompanying it) may contain confidential information, which is protected by law. The information is intended only for the use of the individual addressee named above. If you are not the person to whom this transmission is addressed, you are hereby notified that any examination, review, disclosure, copying, distribution or taking of any action in reliance of the contents of this transmission is strictly prohibited. If you have received this transmission in error, please notify us immediately by telephone to arrange for return of the documents, • PGE 71449 (Dec 2000) CITY OF TIGARD RECEIPT o � 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 187205 - 06/18/2012 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID R0W2012 -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 Credit Card 083705 JFLOYD 06/18/2012 $300.00 Payor: Brian Moore Total Payments: $300.00 Balance Due: $0.00 Page 1 of 1 Ili" 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 ® City Staff (check one) REFUND OR Name: PGE INVOICE TO: (Business or Individual) Mailing Address: 9480 SW Boeckman Rd City/State /Zip: Wilsonville, OR 97070 Phone No.: 503 - 570 -4409 PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓): n CANCEL PERMIT APPLICATION. Fl REFUND PERMIT FEES (attach receipt, if available). ❑ INVOICE FOR FEES DUE (attach case fee schedule and explain below). ❑ REMOVE CONTRACTOR FROM PERMIT (do not cancel permit). Permit #: ROW2012 -00057 Site Address or Parcel #: SEG819 Project Name: PGE Subdivision Name: Lot #: EXPLANATION: Fees should be 0, no fees for this project per GNB 'el Signature: Date: 6 -21 -2012 Hap Watkins 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 Sys Admin: Date By Rte to Bldg Admin: Date By Refund Processed: Date By Invoice Processed: Date By Permit Canceled: Date By Parcel Tag Added: Date By Receipt # Date Method Amount $ l:\ Building\ Forms \RegPermitAction.doc Rev 07 /26/07