ROW2012-00045 VOID
. 11 1
'I Community Development 7/0//
E/-
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: I I Owner Applicant n Contractor ® 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 (V):
® CANCEL PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach receipt, if available).
n INVOICE FOR FEES DUE (attach case fee schedule and explain below).
n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: ROW2012 -00045
Site Address or Parcel #:
Project Name:
Subdivision Name: Lot #:
EXPLANATION: ROW permit not required not in Tigard's jurisdiction
Signature: AlbAkitt Stttl Date: 4/27/12
Shirley 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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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° /u 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 By Rte to : dmin: Date 7Q,7® B ' 7 '
Refund Processed: Date AT , By 4: Invoice Processed: Date By
Permit Canceled: Date 2/0j/0Z. $ Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPemvtAction.doc Rev 07/26/07
\ /fIn
APPLICATION FOR
WORK IN RIGHT -OF -WAY (ROW) PERMIT =
Development Engineering TIGARD
13125 SW Hall Blvd.. Tigard. 0/? 97223 (503) 639 -4171 F.-1.X (503) 624 -0752
FOR STAFF USE ONLY
General Information:
Right -of -Way WW.. 0/A— ODU`f.(
Property Address /Location(s): SW Uplands Dr / Roshak Rd Case No.:
S b Receipt No.:
Date: Y/.-? // a
*Applicant's Name. Natural / Diana Way Application Accepted By: 5-1
Address. NW 2nd Ave Revised 3/4/09
City /State: Portland OR Zip :97209 ¢• 2 7 r e ill
Primary Contact: Bob Keller REQUIRED SUBMITTAL INFORMATION
Phone: 226 -4211 X 3046 Fax: 503- 273 -4822
Contractor's Name: 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
• Subdivision Infrastructure
Plans By: • Main utility line extension:
Address:
City /State: Zip:
Phone: Fax:
Description of work: Raising 2" gas main to gain separation
from other utility and bring up to standards. R00007363. For questions on the design of this job, please contact
Bob Keller at 503 816 0299.
Estimated value of work (within the public right -of- way): $
Is work related to a LAND -USE DECISION? YES u 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.
71 —i L 6 E1
c. documents and serongs \caMdesktop \raw permit appllcation.docx
•
CROSS SECTIONS GENERAL NOTES N
I Call the following t Ittlrttes Notification Center
48 hours poor to any excavation W E
' Oregon l- 80J-332.2344
Washington I -ROB -424 -5555
2. fill out construction sketch es-built supplied with S NOTE: RAISE PIPE IN PUE TO GAIN
job packet and return with work order. Only one SEPERATION 0+72 TO 1 +15
es -built is required
3. All distribution mains must have a minimum depth of
24' and services must have a minimum depth of II"
unless there is an approved variance Q
4. All transmission lines must have a minimum depth of I41 CI
30" in Class 'I' locations and 36' in Class '2. 3, & 4'
locations unless there is an approved variance. r .
5 Written dimensions on this constru ction sketch IIm -i iT
have precedence over scaled dimensions I g
_ VARIANCE (s) _ -. 6 Pressure test shall be tested in accordance with - $ $
standards in ON and Engineering Standard Practice.
vrttsanulal taaN. 7 Test medium for class 'B' main shall be air. unless _ : (
ern of rioted. Test median for clan'C -F' main s ' •I 0
otherwise r
ReaaaaMk -- - shall be water, unless otherwise noted. � `- ,o ai
II For Class C or higher tests. see Design Document and TIE x • - -- - - TIED
,,,aa„R„aaR„ — - ffydrosWttc Repon. SW aoo MILAN LN.
AM.aa. u...: - 1awat"a r ot TIED j ,Il .._p4 � [TIED
�b� X A,3 , A *Inn I1
Class "B" PRESSURE TEST INFORMATION (circle & label test area on as -built drawing) cDo)
Test by NNG -Other •• , ` I N ,
1, ... PtP. air• Fir. Tr CO OFF tAa. n.,rN�...wwsr L• O►) 109' INSTALL: •
N
A ale mu F."a• ft.... Nile Two Nile n.. rat FUSES m �1u ' 7. ! 3 � 3 13E34 ❑ LW
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INSTALL: 40 � f c a—ur, v� °t,' r 9D) ❑ 1 #Anode
B Y Q t .• 17P)
C ❑ LW X Q i 013090
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sy no 6 WELDS CERT. OPER. PM PM to „. A 1 • � , � D
FOOTAGE SIZE M P GRADE W.T. RAYED MAOP MAOP NOP ACTIVITY # ORDER # s 1
INSTALL 43' 2" P B P24 .216 60 57 45 116 03359976 '. g / ti ❑ CUT a CAP
ARAN 43' 2" P B 116 03360227 41V4935:1
TIED i' i t
SW PALERMO LN. - . ''
• NW Natural F eet TIED + a139r5
Engineering Department in = 100 ft 1 J 1 31 _ 19e)
ADDRESS CRY COUNTY STATE DESIGNED RMK DATE 04/18/201: T� - -� �
SW UPLANDS DR PORTLAND WASHINGTON OR DRAWN KDC DATE 04/19/201: x13994 '
tltniti! AND APPROVEDPa q/ k Z 67 DATE .1l2DITji 1�P13T (9a)
SW ROSHAK RD SW MILAN LN e
NAM CREW LDR. P LATTED DATE „ • •
SOUTH CENTER QA _- DATE -----
PLAT TVA1 RAO 1!C JOB TYPE:
Relocates/Abandonments
1- 044-013 TO2S ROt W SW 5 Pat a: PROJECT/REwSDNP
_ 03359976 00007383
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