ROW2014-00023 RECEIVED
MAR 102014
City of Tigard G►N OF TIGARD
Application For Work In The Right-Nt'" ' v'INEERING
TIGARD ROW Permit
Property Address/Location(s):
15935 SW BULL MOUNTAIN RD FOR STAFF USE ONLY
Tigard OR 97224 SEC 111 tp
Right-of-Way
Case No.: 1 O W a"?0 0 00.13
*Applicant's Name: Comcast Cable
6 916 NE 4 0TH ST Application Accepted:�L By: �$0-14-
Address: Application Reviewed: By
City/State:VANCOUVER, WA Zip: 98661
Application Fee Due:
Primary Contact Randy Shields
Mobile 360 3 01-19 6 2 Applicant Notified:
Phone: Fax: Receipt No.:
Randy_Shields@cable.comcast.cable.com P
Email:
REQUIRED SUBMITTAL
Contractor's Name: Fisk Communication Contracting INC INFORMATION
CCB# ORCCB# 185632 Expiration:
• Application form,completed and signed
Address: 2705 NE 65th Ave • Submit one(1)copy of scaled sketch of
City/State: Vancouver WA Zip: 98.661 the proposed work to be done
phone: 360 314-4454 Fax, 360 314-4456 • Submitone(1)copyoftrafficcontrol
Email•
FCCLOCATES @COMCAST.NET plan
Professional Engineered Plans are required
Plans By: IL:01J n3 0 6 ate- o - 0.-P/o for:
Address: • Street Widening
City/State: Zip: • Subdivision Infrastructure
Phone: Fax: • Main utility line extension
Rn.6/24/2013
Email: [:cuipIn1,masters\land use applications\row app.docx
Descriptionofwork: Directional drill from PED on the WEST side of SW BULL MOUNTAIN RD
going EAST 17 ' across road placing a 3/4" pipe with CATV to service 15935 SW
BULL MOUNTAIN RD.
Estimated value of work(within the public right-of-way): $ 6 00 . 0 0
Is work related to a LAND-USE DECISION? YES n NO
If so, please specify(MLP,SDR,SUB,etc.)case#:
Is the work related to a BUILDING PERMIT? YES n NO la
If so, please specify(BUILDING PERMIT)cast#:
Signature of Applicant/Permittee: A / Lam.A I A A_ A- . Date: "NCH 10TH, 2014
Print Name MARGARITA VEGA Ti, ADMINISTRATIVE ASSISTANT
City of Tigard I 13125 SW Hall Blvd.,Tigard,OR 97223 I 503-718-2464 I www.tigard-or.gov
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i\nsz 6 N - 1 Contracting Inc.
D ce c\o0c�,\ (3 60) 314-4454
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City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
711 _ It q
Request Permit Action
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 ❑ Applicant ❑ Contractor ® City Staff
(check one)
REFUND OR Name: N/A no fees assessed.
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
® 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 #: ROW2014-00023
Site Address or Parcel #: SEG 1776
Project Name: Comcast
Subdivision Name: Lot #:
EXPLANATION: Right of way under Washington County jurisdiction. Permit not needed.
Signature: Date: 3-10-14
Cheryl Caines
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°%o 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 809/0 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 retumed 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 Bldg Admin: Date By
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date By Parcel Tag Added: Date By
Receipt# Date Method _ Amount$
I:\Building\Forms\RegPermitAction.doc Rev 05/25/2012
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT (" �� IP
Request Permit Action V 0 1
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov 3 Z.S /
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 ❑ Applicant El Contractor ® City Staff
(check one)
REFUND OR Name: N/A no fees assessed.
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (1):
® CANCEL/VOID PERMIT APPLICATION.
n REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
n INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
n REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit #: ROW2014-00023
Site Address or Parcel #: SEG 1776
Project Name: Comcast
Subdivision Name: Lot#:
EXPLANATION: Right of way under Washington County jurisdiction. Permit not needed.
Signature: (..,t-L ' a . l.eA -,'"J� Date: 3-10-14
Cheryl C es
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%of the building plan review fee when an application is canceled before any plan review effort has been expended.
c) not more than&t"a 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 ii:, Rte to Admire: Date 3 S /y By a.17I
Refund Processed: _ Date_ ^/ ,q- By 41. Invoice Processed: Date By
Permit Canceled: Date �c f j y By Parcel Tag Added: Date By
Receipt# Date / Method Amount$
i:\liudding\rorrns\iwermitnetion.doc Rev 05/25/2012
RECEIVED
MAR 10
City of Tigard Cr7Y
OF 7-/G
ARD
Application For Work In The Right- r / /NEER/NG
TIGARD ROW Permit
Property Address/Location(s): 15935 SW BULL MOUNTAIN RD FOR STAFF USE ONLY
Tigard OR 97224
Right-of-Way
Comcast Cable CaseNo.: �Ol.4 ?ol4- poCIA 3
*Applicant's Name: Application Accepted:iL By: 9_/O-14-
Address: 6916 NE 40TH ST
Application Reviewed: By:
Gm/state:VANCOUVER, WA zip: 98661
Application Fee Due:
Primary Contact: Randy Shields
Applicant Notified:
Phone: Mobile 360 301-1962 1_a,:
Randy_Shields@cable.comcast .cable .com Receipt No.:
F:mail:
REQUIRED SUBMITTAL
Contractor's Name: Fisk Communication Contracting INC INFORMATION
CCB# ORCCB# 185632 Expiration:
Address: 2 7 0 5 NE 6 5th Ave • Application form,completed and signed
• Submit one (I) copy of scaled sketch of
Cin•/State: Vancouver WA dip: 98661 the proposed work to be done
Phone: 360 314-4454 I:„: 360 314-4456 • Submit one (1)copy of traffic control
L-mail:
FCCLOCATES @COMCAST.NET plan
Professional Engineered Plans are required
Plans By: II Q nJ O ac-c- of-- e fm:
Address: • Street Widening
Cin•/State: Zip: • Subdivision Infrastructure
Phone: Fax:
• Main utility line extension
L=mail:
t./24/2013
Description of work: Directional drill from PED on the WEST side of SW BULL MOUNTAIN RD
going EAST 17 ' across road placing a 3/4" pipe with CATV to service 15935 SW
BULL MOUNTAIN RD.
Estimated value of work(within the public right-of-way): S 600 . 00
Is work related to a IAND-USE DECISION? YES n NO X
If so, please specify(MLP,SDR,SUB,etc.)case#:
Is the work related to a BUILDING PERMIT? YES NO n
If so, please specify(BUILDING PERMIT)case#:
Signature of Applicant/Permittee: A/V A AA, Date: MARCH 10TH, 2014
Print Name: MARGARITA VEGA Title: ADMINISTRATIVE ASSISTANT
City of Tigard I 13125 SW Hall Blvd.,Tigard,OR 97223 I 503-718-2464 I w w.tigard-or.gov