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ROW2012-00079 CITY OF TIGARD RIGHT OF WAY PERMIT COMMUNITY DEVELOPMENT Permit #: ROW2012 -00079 13125 SW Hall Blvd., Tigard OR 97223 503.718.2421 Date Issued: 09/05/2012 TIGARD 13125 SEG1019,SEG3044,SEG3569 Jurisdiction: Site address: Subdivision: Lot: Project: Integra Telecom Project Description: Adjacent to 12447 SW 69th Ave., 12540 SW 69th Ave., and 12395 SW 68th Ave. Direct bore 1,240' of 2" conduit and 146' of 4" conduit. Place (1) 2'x3' handhole and (1) 17 "x30" handhole. Work order C9555.WHL.12.ND.12JM.SUC. Owner: FEES Description Date Amount ROW Permit Fee 08/28/2012 $300.00 PHONE: Contractor: PHONE: FAX: Applicant: PAUL JENSEN 1201 NE LLOYD BLVD., SUITE 400 TIGARD, OR PHONE: 503 - 453 -8320 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 G 1 Signature: Issued By: Special Conditions (See Attached) Note: THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for ROW2012 -00079 Type: Condition Name: Status: Severi : ROW 01- CUSTOM CONDITION Applied Notice Submit pot hole pavement restoration detail to inspector before beginng work. 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. I 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 9 P p p Y p 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. 1 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. I / Il N City of Tigard . . Application for work in the Right -of -Way ROW Permit TIGARD General Information: FOR STAFF USE ONLY Property Address /Location(s): 124 S N Lp 97"H RUE Right -of -Way ``� CaseNo.: ()iN aCta)-coo 7C' Ili 1 Receipt No.: I gj { (p (.G *Applicant's Name: EL E !I C LI C T � Il vE Date: - o� cGj. t a Address: 1 1 NE L L t� JD BLVD d I TE /0D Application Accepted By: C- - C- c"— � VT L9�D 6k Zip: q 7'2 82 Revised 7 /1/11 City/State: p: 12 8 .30 Z ,I o �, Primary Contact: PAU �ETUSE.IV REQUIRED SUBMITTAL TAL Phone: 503- 2 15E- 8320 Fax: .O3 - 82gy INFORMATION Contractor's Name: -S-19 N DR RD UZIL1 Ll CPZ lRAQCX-S Submit a scaled sketch of the proposed CCB# LP Lo q B Exp t7 c' 2Y " work to be done Address: 1Z0 E H L E N i NE City/State: RU QORlrl R Z DZ • Traffic Control Plan Phone: E 02 - 5 )1 1-- `ig 223 Fax: 3 O 3 1 V I g" 2721 • Filing Fee $300.00 Plans By: I:curpin \masters \land use applications \row app.docx Address: City/State: Zip: Phone: Fax: ti Description of work: DI. S ECT BODE l 2 `t(` OF 2 CONDUIT AND 1.411' OF H CONDUIT. PLACE (1) 2X3' HRRNDNOLE AND (1) I7x 3d' HANDHO LE.. 'NOtk 1KtEe 0.g5.S5.W41 L. 12. ND_ 12 J NL SL1C Estimated value of work (within the public right -of -way): $ 29 12 D.8° Is work related to a LAND -USE DECISION? YES NO I g If so, please specify (MLP, SDR, SUB, etc.) case #: i � Go�nt P2 t tter Is the work related to a BUILDING PERMIT? YES NO Tic p�� , � If so, please specify (BUILDING PERMIT) case #: ��� J� (��I �rr ` p; om 9/5- CoM City of Tigard I 13125 SW Hall Blvd., Tigard, OR 97223 I 503 - 718 -2468 I www.tigard- or.gov I Page 1 of2 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 Submittal Elements" box. *NOTE: Person specified as "Applicant" shall be designated "Permittee" and shall provide financial assurance for the work. *When the owner and the applicant are different people, the applicant must be the purchaser of record or a lessee in possession with written authorization from the owner or an agent of the owner. The owner(s) must sign this application in the space provided or submit a written authorization with this application. BY SIGNING BELOW, THE APPLICANT(S) SHALL CERTIFY THAT: • The above request does not violate any deed restrictions that may be attached to or imposed upon the subject property. • If the application is granted, 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, are true; and the applicants so 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 entire contents of the application, including the policies and criteria, and understands the requirements for approving or denying the application. . 0 \ � ► 0 1,� 1 . Applicant's Signat Date Owner's Signature Date Owner's Signature Date Authorized Agent's Signature Date FR 1L SEl SEN SR ©5 ENGINEER 503 - 8320 Print Name Title Phone Number Signatures of each owner of the subject property are required City of Tigard I 1 13125 SW Hall Blvd., Tigard, OR 97223 I 1 503-718-2468 I 1 www.tigard-or.gov I 1 Page 2 oft - 44 CITY OF TIGARD RECEIPT 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 TIGARD Receipt Number: 188166 - 08/28/2012 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID R0W2012 -00079 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 162265 TLEHRBACH 08/28/2012 $300.00 Payor: Integra Telecom Total Payments: $300.00 Balance Due: $0.00 Page 1 of 1 I I I I rus I —s • I I I f- -s I 12323 �_ I 1 1 sa' I j i ~ INTEGRA TO s I I —4. — 5 . INTEGRA TO DIRECTIONAL BORE 4 VZ.36453 60' PL 24" X 36" HH 61 } I (1) 2" HDPE � 0. m f INTEGRA TO PL I 021 -01A a 17" X 30" HH 17' 111. 41-- I I i I HOAl22 ?11" I o +no ct 4-36' I 8' 6' 6' I s. I 9' I 8' 16' -- Ill' } LUNCH RM I w I 7 +91 W - =791' R /N - . — . — s ' (.7 1 f - 36' — • • —W -W =449' •R/W - • 4 • — • - • EXISTING FT I" TE ANCHOR INtEGRA ALREADY ATTACHED DEMARK _ ` R/L - I VI— ' M i% EXISTING ELI DG ATTACHED L =1 • H- C X /s I I 30' sNV I s ` 30' I tiv- Pi j v o� t : .m t I + I ' INTEGRA TO - I — — — — — 60 ' — 32 — — — — — 321 — — — —60' — � . 4 I DIRECTIONAL > g +g; I SW FRANKLIN ST Q • BORE (1) 4" HDPE 30' I 30 I w SAN s/W _ 12447 Z I I co L. — RNV — 6' 6I—•► I - ~ 6. INTEGRA TO INTERCEPT I --- - s' - I a EXISTING 4" PVC INTO I g I —9 Z s CUSTOMER DEMARK ROOM f -24' cL SERVER RM ¢ 0 I I i - 36' --Ill. r 6 I 1411----60' ►I P I l' 60' - ' 1 — — — — — — — — — I I r wi I I I H I s, smi , , I N I In SI L-BEV.ELANL> -RRD 81730 "`"; 22333,334 -� 1 HANDHOLE \ 3! t I I I � CO Y` 1(4' 1 DEx11° CONTACT i 1_`t'POi" NIATIlO I I 1 1 1 " ( NOMINAL INSIDE DIMENSIONS) ✓ �. 1 1 1 1 1 1 1 1 1 1 i ii i ll �`i 2 ' I - - /'/ 1 i I i I i I I i i i i i I Cttt:.'dtss'3 - '�ij?ittli G -Jkt (503,635-2039 1 1 1 1 1 1 T I-i � I� -yi.- y .# ,.1 _1,1� I i 1�1 �1�1� y a J 3 err-Ca 1&O kE -' - T_+ T T M3173037E1_ /503 317 d3§ I h 1 T i T I T I i I T I T i- r ITIIITI _ Paul Jensen- regl+ it` ke( 0314534320 f , �` 4. Gar, Pier att- team (S i-&t9 3$72 -2665 f- -- 33 1/4' S. DUrrol Wrs Trrty-JStandard Litany Cwastsuction- -Cef (503,049-4828 4------ -- )' ,< 1.. This work order will require to place fiber lashed to new l nx stand along with all assorted hardware required. 1 ` ,,e , � ,, . 2. CAUTION: Facilities shown on this pion were obtained from records and /or visual surface inspection . ; ` 1/ * ", THOMAS GUIDE: PG -655 / G -4 • 3, Some facilities may be omitted, or shown at an incorrect to cation. baba location of off facilities must i [ ; ./ 1 MAP ID: 2S1 W01 AA I I V 12- C V/1730E% Be determined prior to start of construction. <••-,''',,,,,,,,.1-,,,N,5_,,-'' < FLECTR C 4. Typical minimum conduit depth to be 3 to 6t7" at mad crossing(s). During construction, typlctel depth 6" . I I,,e �� LV/7I �� I to ra .I May be adjuster! lower to avoid conflict with existing underground facilities- ` - i ; 5. All materials, method of placement, and restoration must meet the requirements of City of Tigard. TELECOM �. 1 201 NE LLOYD BOULEVARD 503) 453 -80020 OFFlCE 6. Primary method of conduit placement Will be Trenching and or Directional Baring. SUITE 500 503) 453 -8221 FACSIMILE PORTLAND, OR 97232 7. Contractor to contact Oregon Utility Notification Center prior to start of any work. PL FIBER (a7 CAPITAL ONE Please Call (503) 2454699 or 124-5555. REY DE: u�IP1ON BY DATE JOB 1 of 1 SHEET NO. B. Contractor to pot hole all utility crossings prior to directional boring. EN tIEm J.BIELEC PHONE 360- 213 -4368 9. Maintain minimum I' vertical separation from Water, Sanitary and Storm lines. DATE 8/21/12 FAx NO. 503 - 453 -8284 1.0, New and existing aerial facilities to be bonded and GAD' at oil accessible locations along the aerial route. C9555.WHL.12.ND.12JM.SUC - PROJECT N0. FILE NAME 12447 SW 69TH AVE NTS SCALE 1" _ _ 1