ROW2014-00063 CITY OF TIGARD RIGHT OF WAY PERMIT
= COMMUNITY DEVELOPMENT Permit#: ROW2014-00063
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2421 Date Issued: 06/12/2014
Parcel: SEG552
Jurisdiction: Tigard
Site address: 11492 SW 115th AVE
Subdivision: Lot:
Project: NW Natural
Project Description: Adjacent to 11492 SW 115th AVE Install long side service. Main on the 15' ROW. Possible street cut.
Owner: FEES
Description Date Amount
ROW Permit Fee 06/12/2014 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
NW NATURAL
220 NW 2ND AVE
PORTLAND, OR 97209
PHONE: 503-226-4211
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 /� t Pi-es Signature: `�`�r 7 7
Issued By:
Special Conditions(See Attached)
Note:THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for ROW2014-00063
Tvpe: Condition Name: Status: Seven :
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.
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.
Conditions for ROW2014-00063
Tyke: Condition Name: Status: Severity:
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.
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.
RECF; E
City of Tigard JUN 0 9 2014
UPI
II C17Y p �`GR 4
■ Application for Work in the Right-O f-WNrlvc/Et`J�;NE
ERING
TIGARD ROW Permit
r Address/Location(s):
11492 SW 115th Av FOR STAFF USE ONLY
Property ry
WR#3413878
Case No.: ^6vv 20 I y, ovbcp3
NW Natural
*Applicant's Case No.: ,
Applicantt s Name:
Address:
220 NW 2nd Av Application Accepted: 69/q1 By: (�-
Portland OR 97209 Application Reviewed: 6 'N By:.t3
i
City/State: zip:
Primary Contact:Judy Doblie
Phone: Fax: $300.00 Application Fee D e: Ye $q
0
503-226-4211 X 4428 503-273-4822 Applicant Notified: (6 t I ol- I `i I
Email:nwnpermits @nwnatural.eom Receipt No.: �D CD dZ
Loy Clark/Wanda Taylor REQUIRED SUBMITTAL
Contractor's Name: INFORMATION
CCB#52281 Expiration:
• Application form,completed and signed
Address:PO Box 1369 • Submit one (1)copy of scaled sketch of
City/State:Tualatin OR Zip:97062 the proposed work to be done
Phone:503-783-1171 Fax:503-520-8763 • Submit one (1)copy of traffic control
Email:wandat @loyclark.com plan
Professional Engineered Plans are required
Plans By: for.
Address: • Street Widening
City/State: Zip: • Subdivision Infrastructure
Phone: Fax: • Main utility line extension
Email: l:curptn\masters\land use applicanons\mw app.docx I Rev.7/19/12
Description of work: Install long side service. Main on the 15'in ROW. Possible street cut.
Estimated value of work(within the public right-of-way): $
Is work related to a LAND-USE DECISION? YES D NO l
l
If so, please specify(MLP,SDR,SUB,etc.)case#: I
Is the work related to a BUILDING PERMIT? YES fl NO n
If so, please specify(BUILDING PERMIT)case#:
�- �: .a..� �,.,�,:.= 6/9/2014
Signature of Applicant/Permittee: om,.o.�o,�.aa� Date:
Print Name:Judy Doblie Title:Engineering Coordinator
City of Tigard I 13125 SW Hall Blvd.,Tigard,OR 97223 I 503-718-2464 I www.tigard-or.gov
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CITY OF TIGARD
I RECEIPT
I� � 13125 SW Hall Blvd.,Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 196462 - 06/12/2014
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
R0W2014-00063 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 079351 BGALICIA 06/12/2014 $300.00
Payor: Brian Kelly
Total Payments: $300.00
Balance Due: $0.00
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