ROW2012-00017 , CITY OF TIGARD RIGHT OF WAY PERMIT
: COMMUNITY DEVELOPMENT Permit #: ROW2012 -00017
Date Issued: 03/02/2012
ArIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2421
Parcel: SEG2434
Jurisdiction: TIGARD
Site address:
Subdivision: Lot:
Project: Frontier Communications
Project Description: In front of 16045 SW Upper Boones Ferry Rd., enter vault on eastside of street near curb pull in cable for
service across street at 16083 SW Boones Ferry Rd
Owner: FEES
Description Date Amount
ROW Permit Fee 02/24/2012 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
FRONTIER COMMUNICATIONS
4155 SW CEDAR HILLS BLVD
BEAVERTON, OR 97005
PHONE: 503 - 643 -0371
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: �l
I
PAI.A.$4&03
ssued By:
Special Conditions (See Attached)
Note: THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for ROW2012 -00017
Type: Condition Name: Status: Severity:
ROW 01- CUSTOM CONDITION Applied Notice
No placement of materials or equipment in the street from 7.00 to 9:00 am and 3:30 to 6:00 pm.
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 Zen Dutson, at 503 - 718 -2472 or email at
zen @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 snot 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.
CONSTRUCTION NOTES CABLE raecE TEA/WWI. TEA/WWI. I I TER - I
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6NMTURE P.0 R.T[T
TITIFl.O XT.IL6
TGRO - PLC CA FOR RELIEF COUNT
16883 SW UPPER 800NfS FERRY RO.
NOTE AREA -- - o Po®o' .FRONTIER qwN AREA STATE: OR
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a CONDUIT OILY MUNICIPALITY X TITLE: TGRO -PLC CA FDit REL C _ TAX 05T.2
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FIELDEO By FILE: 16-1 D RHt1 Er$ APRVD PRINT
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1,1 a City of Tigard
Application for Work in the Right -of -Way Permit
TIGARD
GENE INFORMA REQUIRED
SUBMITTAL
Property Address/Location(s): 16045 SW BOONES FERRY RD. AT THE INFORMATION
INTERSECTION OF SW 72 AVE. 3ct Submit a scaled sketch of the
proposed work to be done.
FRONTIER COMMUNICATIONS • Traffic Control Plan
'Applicant's Name: • �, Ct,r c' c(
Filing Fee $300.00 hD
Address: 4155 SW CEDAR HILLS BLVD
BEAVERTON /OR 97005 �1 a L� 2 - • rZ
City /State: Zip FOR STAFF, USE ONLY
Primary Contact: JOHN COUSINEAU Right -of -Wa
Phone: 503- 643 -0371 Fix 509 - 643 -0977 Case #: /6010.0.101,37 - 4017
Receipt #:
Contractor's Name: FRONTIER COMMUNICATIONS Date: bc)--\_
CCB # 49350 Expiration: Application Accepted By: ..1126 .
Address:
8840 SW BURNHAM ST. Retired 07/01/2011
City /State: TIGARD /OR Zip: 97223
Phone: 503 - 936 -2091 Fax:
Plans By: JOHN COUSINEAU
Address: 4155 SW CEDAR HILLS BLVD.
City /State: BEAVERTON /OR Zip: 97005
Phone: 503 - 643 -0371 Fax: 503 - 643 -0977
Description of work: ENTER VAULT ON EASTSIDE OF STREET NEAR CURB PULL IN CABLE FOR
SERVICE ACROSS STREET AT 16083 SW BOONES FERRY RD.
Estimated value of work (within the public right -of -way): $ $3000
Is work related to a LAND -USE DECISION? ❑ YES 111 NO
If so, please specify (MMLP, SDR, SUB, etc.) case #:
Is the work related to a BUILDING PERMIT? YES 1/1 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 1 of 2
free re _ �'"
9 A?red
APPLICANTS: To consider an application complete, you will need to submit ALL of the REQUIRED SUBMITTAL ELEMENTS
as described on the front of this application in the "Required Submittal Elements" box.
' NOTE: Person specified as "Applicant" shall be designated "Peunittee" and shall provide Financial assurance for the work.
• When the owner and the applicant are different people, the applicant must he 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 APPLICANT(S) SHALL CERTIFY THAT:
• The above regoest does not violate any deed restrictions that may be attached to or imposed upon the
• subject property.
• 11 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 application, inchiding 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
z
/ Y
Authorized Agent's Si4 tature
late
/ t
_ „�.......,, 4.,./ , ^� ,i..,' %'' ;'r�..,. °' f , t _ d' <t./ 3`�p.. Y'�..., !' t�. 'a . ° � 0 i `... C.,�°c''I -- - e,1... 1
Print Name Tide Phone Number
Signatures of each owner of the subject property are required.
(m Til tul I 13125 SW Hall Blvd., Tigard, OR 97223 503-713-2464 I www.tigard-or.gov I P ge 2 of 2
.. ° ' (C)\: MI ' 7 , `-\\ I "'
U - -2 /
TIGARD
City of Tigard
March 14, 2012
Frontier Communications
Attn: Fran Hoag
4155 SW Cedar Hills Blvd.
Beaverton, OR 97005
Re: Permit No. ROW2012 -00017
Dear Ms. Hoag:
The City of Tigard has processed a refund for fees on the above referenced permit(s) as
follows:
Site Address: 16045 SW Upper Boones Ferry Rd
Project Name: Frontier Communications
Job No.: N/A
Refund: ❑ Check # in the amount of $ .
® Credit card "return" receipt in the amount of $300.00.
Note: Please allow 2 -5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account "deposit" receipt in the amount of $ .
Comments: Refund 100% of permit fee as not required for this ROW permit.
If you have any questions please contact me at 503.718.2430.
Sincerely,
/02(.
Dianna Howse
Building Division Services Supervisor
Enc.
I:\ Building \Refun r ' SnSl3. otialtadriaCke Itril ggiii, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard- or.gov
Et1
City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building application
fees. Receipts, documentation and the Request for Permit Action form (if applicable) must be attached
to this request. Refund requests are due to Accela System Administrator by Wednesday at
5:00 PM for processing by the following Wednesday. Accounts Payable will route refund
checks to Accela System Administrator for distribution. Please allow up to 2 weeks for processing.
PAYABLE TO: Frontier Communications DATE: 3/14/2012
Attn: Fran Hoag
4155 SW Cedar Hills Blvd REQUESTED BY: Dianna Howse
Beaverton, OR 97005 KJP
TRANSACTION INFORMATION:
Receipt #: 185656 Case #: ROW2012 -00017
Date: 2/24/2012 Address /Parcel: 16045 SW Upper Boones
Ferry Rd
Pay Method: CreditCard Project Name: Frontier Communications
EXPLANATION: Refund 100% of permit fee as not required for ROW application per Kristie Peerman.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000 -43104 ' - • $ Amount
ROW Permit Fee 100- 0000 -43114 $300.00
TOTAL REFUND: $300.00
APPROVALS:
If under $5,000 Professional Staff
■
`
If under $12,500 Division Manager ,/ 77
If under $25,500 Department Manager
If under $50,000 City Manager
If over $50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONL
•
Case Refund Processed: Date: _ / /y / /�_ By: I 'd
I:\ Building \Refunds \RcfundRcqucst.doc x 09 /01/2010
Community Development
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 n Applicant n Contractor 7 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 ( ✓):
- ' CANCEL PERMIT APPLICATION. bo No c C- c c l . K P 3/LrZ
REFUND PERMIT FEES (attach receipt, if available).
INVOICE FOR FEES DUE (attach case fee schedule and explain below).
n REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: ROW2012 -00017
Site Address or Parcel #: 16045 SW Boones Ferry Rd
Project Name: Frontier
Subdivision Name: Lot #:
F �- D
EXPLANATION: Permit n ot required , R.a. 4 x 600 0 - iC• C.trw�s 3/l b a. •
cov-4di•Q - P 3 l271
Signature: 4Y Date: 2/28/2012
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` o of the land use application fee for issued permits.
d) not more than 80° /s 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 B Rte to Adtnin: Date &A7 B /ii s=
>! nd Processed: Date -21/5 -- Invoice Processed: Date B
it Canceled: Date ..g/2-//2___ By �� � . Parcel Pl Tag Added: Date By
_ Ef r rm
Receipt # / S 5( DateA 24' I Method �! Amount $ �p- fl , y
I:\ Building \Forms \RegPermitAction.c3oc RCv 07/26/07