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ROW2013-00029 CITY OF TIGARD RIGHT OF WAY PERMIT 11111- COMMUNITY DEVELOPMENT Permit#: ROW2013 00029 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 04/17/2013 Parcel: SEG3442 Jurisdiction: Tigard Site address: Subdivision: Lot: Project: Frontier Communications Project Description: Adjacent to 8625 SW Inez St. Storm Sewer repair requested by City. SEG 3442. Owner: FEES Description Date Amount ROW Permit Fee 04/17/2013 $300.00 PHONE: Contractor: PHONE: FAX: Applicant: ANDREW MULICK 4155 SW CEDAR BEAVERTON, OR 97005 PHONE: 503-526-3544 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: . -;16PIA Issued By: 6 Special Conditions(See Attached) Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY Conditions for ROW2013-00029 Type: Condition Name: Status: Sever : 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. 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 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. Also provide repair method. 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. . RECEIVED MAR 1 g 2013 PLA NI OF TIGARD RING City of Tigard t ::v Application for Work in the Right-of-Way Permit „ 9k,.r.,,.�i , 1. GENERAL INFORMATION REQUIRED SUBMITTAL Property Address/Location(s): 8625 SW Inez St. INFORMATION Storm Sewer Repair requested by City Submit a scaled sketch of the SC •��, �, proposed work to be done. C�� • Traffic Control Plan 'Applicant's Name: FRONTIER COMMUNICATIONS • Filing Fee S300.00 p. Address: 4155 SW CEDAR HILLS BLVD "1 BEAVERTON,OR 97005 L 3 . /i ,(3 City/State: Zip: FOR STAFF USE ONLY Andrew Musick Primary Contact: Right-of-Way 503-526-3544 (503)643-0977 Case#:ROVJ2OI3-OCO*2-i Phone: Fax: Receipt#: 1d_1 I C22 Contractor's Name: NORTH SKY COMMUNICATIONS Date: 31ISI 13 CCB#: 1141171 Expiration:03/01/14 Application Accepted By: At- 10860 SW CUTTER DR Raised 07/01/2011 Address: SHERWOOD OR 97140 ) PPI ' C4 k �0+; �; �d 1q City/State: Zip: I� Phone: 503-647-9991 Fax: 503-647-9971 Plans By: Address: City/State: Zip: Phone: Fax: Description of work: Estimated value of work (within the public right-of-way): $ Is work related to a LAND-USE DECISION? ❑ YES NO If so,please specify(M LP,SDR,SUB,etc.)case#: Is the work related to a BUILDING PERMIT? El YES 1 NO If so,please specify(AILP,SDR,SUB,etc.)case#: City of Tigard I 13125 SW Hall Blvd.,Tigard,OR 97223 I 503-718-2464 I www.tigard-or.gov I Page I of 2 APPLICANTS:lb consider an application complete,you will need to submit ALL of the REQUIRED SUBrmI TAL ELEMENTS as described on the front of this application in the"Required Submittal Elements"bos. 'NOTE: Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for the work. 'When the owner and the applicant arc 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 APPLICANTS) 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. Applicant's Signature Date Owner's Signature Date Owner's Signature Date Authorized Agent's Si7 re ate ,,-/A/7)R.eriA` AL/ 63 P �:r/t/��IJI./ .�. 6,2 7 6.i x/Y Print Name Title Phone Number Signatures of each owner of the subject property are required. F:•np:n`:n^;cr 11•a.t u•� T ;i,r..+,:,.,Itt I',:.n:..lpp':...i•iar,i: City of Tigard I 13125 SW Hall Blvd.,Tigard,OR 97223 503.713-2.164 I www.tigard.or.goc I Page 2 of 2 . . CITY OF TIGARD RECEIPT 8 ; ' 13125 SW Hall Blvd.,Tigard OR 97223 . 503.639.4171 TIGARD Receipt,Number: 191022. - 04/17/2013 CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID R0W2013-00029 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 054376 AKOWACZ 0.4/17/2013 $300.00 Payor: John Gaylord Total Payment: $300.00 Balance Due: $0.00 I, . Page,1 of.1 • r t,r r;yall i �L`` 4.......a., M. storm Main i-ormuta-Based TV Inspection Detail +3125 SW Hall Blvd. 1 l Tigard,OR 0223 2 (503)639-4171 Fax(503)684.8840 r i2 U 56 CI Report Date 04/20/2010 03:19 PM Submitted By Page 1 Inspoctlon 0 107338 Work Order# 313449 Activity STFTVI STORM FORMULA TV INSPECTION 1 From ID STMH 11A010 To STIN 11LA008C II Length 344.00 Started 04/20/2010 00:00 342 5 g W J ie Z Sf Crow Leader Reverse Setup ID Prior History Q • Completed 04/20/2010 00:00 , ■ Operator BRENNDM Sketch C) Comp By BRENNDM /DO E€;'.'l UT `o'7 lit' Weather RAIN Media I • Project 4o/A v; 6'6A Flow Depth 0.00 Format SERV Media/I STM 11 Crow Pipe Det Indox To • J ip1;f Hai" fi) Ui/ii(Li cleP.fr r 1- • Surveyed Longth 344.00 Surveyed Diem 18,00 Surveyed Height 0.00 --/drgtlt Ft•r, '&. Val, Comments Li'i5" k IItVu'j L AI I+ WHITE°X"AT PROBABLE LOCATION OF ORANGE PIPE INTERSECTING STORM LINE...©8625 SW INEZ ST....TVI ON 7.19.)6 DOES NOT REFLECT THIS , BEING HERE. Observations n 11A010 • . Setup U From 5.50 To 0.00 Width 0.00 Position To ONset . 0.00 Index \ Observation AMH ACCESS POINT,MANHOLE Measurement 0.000 Rating 0.0000 Dogreo!Sovority 00 00 Grouted N - \ Comments BEGIN AT MH 010 -Setup U From 6.50 To 30.00 Width 0.00 Position 12 To Offset 0.00 Index Obsorvatlon CL CRACK,LONGITUDINAL Medsuromont 0.000 Rating 9.4000 ' DogreelSeverity 02 2 GRADE Grouted N Setup U From 38.00 To 135.00 Width 0.00 Position 12 To ONset 0.00 index Observation CL CRACK,LONGITUDINAL Measurement 0.000 Rating 38.8000 ]N Dogroe/Severlty 02 2 GRADE Groutod N Comments TOP AND BOTTOM I Sotup U From 123.30 To 0.00 Width 0.00 . Position 0 • To 3 Offset 0.00 Indox Observation OBC OBSTACLE,OBJCT THRU CONNECTIO Measurement 0.000 Rating 3.0000 Degree/Soverlty 03 3 GRADE Grouted N • Comments LOOKS LIKE AN ORANGE VERIZON THRU AND THRU...CAMERA GOES UNDER • Setup U From 319.60 To 0.00 Width 0.00 Position To Offset 0.00 Index Observation JSL JOINT SEPERATED(OPEN),LARGE Measurement 0.000 Rating 2.0000 j Degree/Severity 02 2 GRADE Grouted N Comments JOINT IS SEPERATED WITH PIECES OF PIPE AND777SHOVEO INTO GAP 7.Setup U From 323.50 To 0.00 Width 0.00 • Position To Offset 0.00 Index • 7 Obsorvatlon JOL JOINT OFFSET(DISPLACED),LRG Measurement 0.000 Reling 2.0000 Dogree/Severity 02 2 GRADE Grouted N Commonts CAMERA CAN'T CLIMB JUMP JOINT...ZOOMED TO CB i Setup U From 344.00 To 0.00 Width 0.00 _/ Position To Olfsot 0.00 Index I i, ► 11A00t1C Observation ACB ACCESS POINT,CATCH BASIN Measurement 0.000 Rating 0.0000 �J DogreeiSeverity 00 00 Grouted N Comments CENTER9F_CB_008 • s:;rQ 4jdI`?,i - :a�. e .. l�S :�.P- •-•:1,:. ,;''••t e?''rw•• ,,..•y. i:1 O I U �.. :-.',....-.:7.- .` ,: r + i� "$^I u.itww ,, 7. : 'r 2 f4 . .+Ifip• !��• • � 'La ' ':'.=:;...,......;,i'4 ,,,.:4,' I •'',• � r � yI,1 !7 , ttr a$ kt :IIw �rC ws ,, y pr, I" rlr t,rl " h 5' ..A I � _ r b 6,: ,.E°�ti .k I rr�«k. 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