ROW2013-00061 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
_. is Re Request Permit t Act
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov
TO: CITY OF TIGARD
VOID
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223 2 / AS 4
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor t21 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 (1):
E. CANCEL /VOID PERMIT APPLICATION.
n REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
I I REMOVE /REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: R Q v'\J 20 1 -- o UO 6 I
Site Address or Parcel #: CS E G (9 19
Project Name: Corn CCk s
Subdivision Name: ��rr Lot #:
• EXPLANATION: A.. • �" j O (m - S oc�`> it no U
ou b n -... _- +- o -Ala , See cti+adneel
CarfeScDoOcle CS. No `e.uocld
( .2ij2o Signature: � im!' 7 Date: j 3
Pri nt Name:
Refund Policy
I. 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b) not more than 80" ° of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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°o 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 OFFICE USE ONLY
Rte to Sys Admin: Date By Rte to &hit Admin: Date 7 2s /3 By '
Refund Processed: Date By ,./1 J Invoice Processed: Date By
Permit Canceled: Date / Z5,43 By -. Parcel Tag Added: Date By
Receipt # Date Metho• Amount $
I:\ Building \Forms \ReyPermitAetion.doc Rev 05/25/2012
Tim Lehrbach
From: Fisk Communications <fcclocates @comcast.net>
Sent: Thursday, July 18, 2013 10:41 AM
To: Agnes Kowacz
Cc: Margarita Vega; FiskPermits; ROW Permits
Subject: Permit Request -- Comcast Cable -- 8605 SW PINEBROOK DR, Permit number
ROW2013 -00061
Agnes,
Please cancel /close out this permit. Our crew was able to find the existing conduit under the
road. No digging or boring was necessary in the ROW.
thanks
John Hall
Supervisor,
FISK Communication Contracting Inc.
2705 NE 65th Ave, Vancouver WA 98661
360 314 4454
This email and any files transmitted with it are confidential and intended solely for the use of the
individual or entity to which they are addressed. If you have received this email in error please notify
the system manager. Please note that any views or opinions presented in this email are solely those
of the author and do not necessarily represent those of the Company. Finally, the recipient should
check this email and any attachments for the presence of viruses. The Company accepts no liability
for any damage caused by any virus transmitted by this email.
From: "Agnes Kowacz" <AgnesKAtigard- or.gov>
To: "Catherine Sticker" <fcccatherinet gmail.corn >, "ROW Permits" <rowpermitsAtigard- or.gov>
Cc: "Margarita Vega" <fccmargarita ci.gmail.com >, "John H Locates" <fcclocates @comcast.net >,
"FiskPermits" <fccpermitsAgmail.com>
Sent: Thursday, July 11, 2013 12:10:46 PM
Subject: RE: Permit Request -- Comcast Cable -- 8605 SW PINEBROOK DR
Good afternoon -
Please see your attached permit. Thank you.
Agnes Kowacz I Associate Planner
City of Tigard
13125 SW Hall Blvd.
Tigard, OR 97223
503.718.2427
agneskPtigard- or.gov
1
From: Catherine Stricker [ mailto :fcccatherine(agmail.com]
Sent: Tuesday, July 09, 2013 4:34 PM
To: ROW Permits
Cc: Agnes Kowacz; Kristie Peerman; shirley(atigard- or.gov; Margarita Vega; John H Locates; FiskPermits
Subject: Permit Request -- Comcast Cable -- 8605 SW PINEBROOK DR
Hello,
Attached is a ROW permit application and map for above referenced address for your review and approval.
Please contact me if there are any questions or concerns at the office or by email.
Thank you for your time,
Catherine Stricker
FISK Communications Contracting Inc.
2705 NE 65th Ave
Vancouver, WA 98661
Office: 360 - 314 -4454
fcccatherine @gmail.com
This email and any files transmitted with it are confidential and intended solely for the use of the individual or
entity to which they are addressed. If you have received this email in error please notify the system manager.
Please note that any views or opinions presented in this email are solely those of the author and do not
necessarily represent those of the Company. Finally, the recipient should check this email and any attachments
for the presence of viruses. The Company accepts no liability for any damage caused by any virus transmitted
by this email.
DISCLAIMER E -mails sent or received by City of Tigard employees are subject to public record laws. If requested, e-mail
may be disclosed to another party unless exempt from disclosure under Oregon Public Records Law. E -mails are retained
by the City of Tigard in compliance with the Oregon Administrative Rules "City General Records Retention Schedule."
2
CITY OF TIGARD RIGHT OF WAY PERMIT
,t COMMUNITY DEVELOPMENT Permit #: ROW2013 -00061
1 3125 SW Hall Blvd., Tigard OR 97223 5 03.718.2421 Date Issued: 07/11/2013
TIGARD Parcel: SEG1919
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Comcast
Project Description: Adjacent to 8605 SW Pinebrook Drive. Directional drill from the south side of SW Pinebrook Drive going
north to property line, placing 3/4" schedule 80 pipe with CATV service wire to provide CATV service for
8605 SW Pinebrook Dr. SEG 1919.
Owner: FEES
Description Date Amount
ROW Permit Fee 07/11/2013 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
RANDY SHIELDS
14200 SW BRIGADOON CT
BEAVERTON, OR 97005
PHONE: 503 - 828 -3547
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.
tue/Applicant
Signature: P e ,_ ,'
Signature: r / �
�/'�,'/
Issued By: �) 4 •
Special Conditions (See Attached)
Note: THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for ROW2013 -00061
Type: Condition Name: Status: Severity:
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 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.
A PPLICATION FOR
WORK IN RIGHT -OF -WAY (ROW) PERMIT : 7t7 ` :.
Development Engineering t '` th
13125 SW Hall Blvd, Tigard, OR 97223 (503) 639 -4171 FAX (503) 624 -0752
FOR STAFF USE ONLY
General Information:
Rig ht - of - W I
Property Address /Location(s): 8605 SW PINEBROOK I S f Case No.: 11--0
W 20 ' (,0010
"
E L � i cy ( Receipt No.: 1 l el
� Date: llor 11
*Applicant's Name: COMCAST Application Accepted By: I
Address: 14200 SW BRIGADOON CT Revised 3/4/09
BEAVERTON, OR 97005 mot`
City /State: Zip: ,�� 7 • /b • ! � .� 3DE
Primary Contact: Randy Shields REQUIRED SUBMITTAL INFORMATION
Phone: 360 - 828 -3547 Fax: N Dh&c1 ipp — /11111
Contractor's Name: FISK COMMUNICATIONS CONTRACTING Submit a scaled sketch of the
185632 08/01/2013 proposed work to be done
CCB# Expiration:
Address: 2705 NE 65th Ave
zip: p:
VANCOUVER, WA 98661 Professional Engineered Plans are
360- 314 -4454 360- 314 -4456 required for:
Phone: Fax:
• Street Widening
• Subdivision Infrastructure
Plans By: • Main utility line extension:
Address:
City /State: Zip:
Phone: Fax:
Description of work: Directional drill from the SOUTH side of
SW PINEBROOK DR going NORTH to property line, placing 3/4" schedule 80 pipe with CATV service wire, to provide CATV
service for 8605 SW PINEBROOK DR.
Estimated value of work (within the public right -of -way): $ ;385.00
x
Is work related to a LAND -USE DECISION? YES NO
If so, please specify (MLP, SDR, SUB, etc.) case #:
Is the work related to a BUILDING PERMIT? YES 1 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.
i:lengVnike mccVight of wayVow permit apples on.docr
CITY OF TIGARD RECEIPT
'1
I : 13125 SW Hall Blvd., Tigard OR 97223
503 639.4171
TIGARD
Receipt Number: 192191 - 07/11/2013
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
R0W2013 -00061 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 1
Credit Card 103200 AKOWACZ 07/11/2013 $300.00
Payor Meghan Fisk
Total Payments: $300 00
Balance Due: $0.00
1
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