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ROW2012-00065 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V 0 1 i ill _ ~ Request Permit Action a /a �/3 =" TIGARD 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 p Applicant ❑ Contractor X City Staff (check unc) REFUND OR Name: INVOICE TO: (Business or Individual) Mailing Address: City/State /Zip: - Phone No.: PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( ✓): CANCEL /VOID PERMIT APPLICATION. ❑ 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 #: ROtiI 2412-- 0006 5 Site Address or Parcel #: SEG ( 36 Project Name: COmeasf Subdivision Name: (1' Cl_ Lot #: r I a.- EXPLANATION: Ui1t1 n0i-1Ti4 Kenny FIshe -v - fhccl - job Wets Canceled on 8 I I3t2. )4Io r AA,n d rev. est -eel• Signature: Date: 42.01 ►3 Print Name: - TIM Lehrbae,h 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 b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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. FOR OFFI(:I'', I BSI', ()NI.) Rte to Sys Admin: Date By Rte to.. Admin: Date .2/.21 /3 B j Refund Processed: Date i1/ i B .9. voice Processed: Date Permit Canceled: Date A Al /3 By 0 - 7 Parcel Tag Added: Date By Receipt # Date Method Amount $ 1:\ Building \ Forms \RegPermitAction.doc Rev 05/25/2012 I CITY OF TIGARD RIGHT OF WAY PERMIT MI $ COMMUNITY DEVELOPMENT Permit #: ROW2012 -00065 13125 SW Hall Blvd., Ti Date Issued: 07/12/2012 TIGARD and OR 97223 503.718.2421 9 Parcel: SEB1636 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: Comcast Project Description: Adjacent to 10362 SW McDonald St., trench a total of 86 feet and install one 2 -inch conduit a minimum of 36 inches below grade and install a new CATV pedestal within city right -of -way. Owner: FEES Description Date Amount ROW Permit Fee 07/09/2012 $300.00 PHONE: Contractor: PHONE: FAX: Applicant: FRANK ZABEL 9605 SW NIMBUS AVE BEAVERTON, OR 97008 PHONE: 503 - 519 -5021 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: - 'Ptb r Issued By: C14_— Q r 1 �I�l� Special Conditions (See Attached) Note: THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY • Conditions for ROW2012 -00065 Type: Condition Name: Status: Severity: ROW 01- CUSTOM CONDITION Applied Notice Drop along the south side of the pole and place the conduit sufficiently south to avoid the pavement. Pavement cutting is not permitted. 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 (CIT() 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 Kenny Fisher, at 503 - 816 -6146 or email at kenny @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. RECEIVED JUL 0 9 2012 City of Tigard PLANNING/ENGINEERING CII OF A 1 r> 1 11 1 fri .. Application For Work In The Right-Of-Way TIGARD ROW Permit FOR STAFF USE ONLY General Information: Right -of -Way Property Address /Location(s): 10362 SW McDonald Street, Tigard, OR 97224 Case No.: ISO W oZ 0 la' 000 , S S E G 14,3(0 Receipt No.: 18 `"f 6 3 Date: 1 - 9 - I a *Applicant's Name: Comcast Application Accepted By: C. • --) Address: 9605 SW Nimbus Ave Revised 7/1/10 City /State: Beaverton, OR Zip: 97008 7 /5`/2. • 3Da Primary Contact: Frank Zabel - Project #829487 REQUIRED SUBMITTAL Phone: (503) 519 -5021 Fax: (503) 605 -6233 INFORMATION Contractor's Name: Texstar Enterprises CCB# 178798 Expiration: 10/1 0 /2013 Submit a scaled sketch of the proposed work to be done Address: 1220 SE 190th Ave City /State: Portland, OR Zi 97233 Phone: (503) 719 -5436 Fax: (503) 328 -9168 Professional Engineered Plans are required for: Plans By: K &B • Street Widening Address: 4120 SE International Way • Subdivision Infrastructure • Main utility line extension: City /State: Milwaukie, OR Zip: 97222 Phone: (503) 650 -6041 Fax: (503) 650 -7390 I:curpin \ masters \land use applications \row app.docx Description of work: Comcast proposes to trench a total of 86' and install (1) -2" conduit a min. of 36" below grade and to install a new CAN pedestal within the City of Tigard right -of -way. 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 l I NO ❑ 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 I II CITY OF TIGARD RECEIPT 1 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 187463 - 07/09/2012 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID R0W2012 -00065 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 Check 3383 CCAINES 07/09/2012 $300.00 Payor: Tremark, LLC Total Payments: $300.00 Balance Due: $0.00 Page 1 of 1 NOTES: N 1. ALL WORK AREAS TO BE RESTORED TO LIKE OR BETTER CONDITION. 13950' ': WS' E 2. ALL OTHER UTILITIES ARE BASED • OFF EXISTING LOCATES OR UTILITY STRUCTURES. S 3. IT IS THE CONSTRUCTION CONTRACTORS RESPONSIBILITY TO CALL FOR LOCATES BEFORE ROW DIGGING. t I 15' 5' 4. TRENCH SYMBOLOGY - — - - -- - - --- ROW FOC FOC 50' SW MCDONALD ST TO SW 104TH AVE 30' TYP. 60' TO SW 103RD AVE Contact: Frank Zabel Title: Fiber Construction Coordinator 50' Oregon / SW Washington Market NEW CATV PEDESTAL TRENCH AND INSTALL (1) -2" CONDUIT 4' FROM FOC A MIN. OF 36" BELOW GRADE Mobile - (503) 519 -5021 (TYPICAL) Office - (503) 605 -6045 FOC - FO Email - Fra — Z el ab @ c able.comcast.com k —ROW 0 NT/280591 15' O'25 5' — p lQC-L .5 d• a , 1 ea..) 0; - ' — ROW ...... 11' FROM ROW — l r 0 a 9605 SW Nimbus Ave / Beaverton, OR 97008 / i © : 4120 SE INTERNATIONAL WAY SUITE A113 N MILWAUKIE, OR 97222 Email: kbeng @att.net Design By: K & B (503) 650 -6041 / SITE ADDRESS: I 10362 SW McDonald Street / Portland, OR 97224 2S1 W11 NW / i REV. DATE DESCRIPTION APPROVED 1 07/06/12 City of Tigard Permit Drawing i ( _ / SCALE: PROJECT NUMBER; I 1" = 20' B29487 SHEET NUMBER TITLE: FIBER ENHANCEMENT PERMIT DRAWING FILE NAME: I SHEET 1 OF 1 CM M E- 1241 -640 I