ROW2012-00080 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT j`9;, ® I D
Request Permit Action �s/z
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:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEMS) CHECKED (✓):
® 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 #: ROW2012-00080 L`�
Site Address or Parcel #: 9365 SW View Terrace
Project Name: Comcast
Subdivision Name: Lot #:
EXPLANATION: Comcast/Fisk Communications canceled the job. See attached e-mail.
No refund requested by applicant.
Signature: Mf VN Date: 11/1/2012
Tim Lehrbach
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b) not more than 80 of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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"o of the building plan review fee when an application is canceled before any plan review effort has been expended.
c) 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 Admin: Date / ,S /1-- B
Refund Processed: Date B Invoice Processed: Date B
Permit Canceled: Date // ,S /2— B Parcel Ta Added: Date B
Receipt# Date Method Amount$
1:ABuilding\Dorms\RcgPerntitAetion.doc Rcv 05/25/2012
Tim Lehrbach
From: Kenny Fisher
Sent: Wednesday, October 31, 2012 4:58 PM
To: Tim Lehrbach
Subject: FW: 9365 SW VIEW TERRACE, ROW 2012-00080
Follow Up Flag: Follow up
Flag Status: Flagged
From: Fisk Communications [ma ilto:fcclocatesO)comcast.net]
Sent: Wednesday, October 31, 2012 9:03 AM
To: Kenny Fisher
Cc: Steven Loy (fccsteve(-acomcast.net)
Subject: 9365 SW VIEW TERRACE, ROW 2012-00080
Kenny,
ROW2012-00080 is a cancel, there will be no work done for this permit. The homeowner canceled
service with Comcast.
thanks
John H
FISK Communication Contracting Inc.
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."
I
•
CITY OF T RIGHT OF WAY PERMIT
�'
TIGARD ° COMMUNITY DEVELOPMENT Permit #: ROW2012 -00080
13125 SW Hall Blvd Tigard OR 97223 503.718.2421 Date Issued: 09/19/2012
TIGARD Parcel: SEG1794
Jurisdiction: Tigard
Site address:
Subdivision: Lot:
Project: Comcast
Project Description: Adjacent to 9365 SW View Terrace. Directional drill from the east side of SW View Terrace going west to
property line, placing 2" schedule 80 pipe with CATV service wire, to provide CATV service.
Owner: FEES
Description Date Amount
ROW Permit Fee 09/19/2012 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
RANDY SHIELDS
14200 SW BRIGADOON CT
BEAVERTON, OR 97005
PHONE: 360- 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.
c t
Permittee /Applicant
Signature: f.r •4
Issued By:
Special Conditions (See Attached)
Note: THIS PERMIT DOES NOT COVER WORK ON PRIVATE PROPERTY
Conditions for ROW2012 -00080
Type: 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 -6166 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.
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.
CITY OF TIGARD RECEIPT
s 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 188436 - 09/19/2012
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
ROW2012 -00080 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 104676 JFLOYD 09/19/2012 $300.00
Payor: Margaret Fisk
Total Payments: $300.00
Balance Due: $0.00
Page 1 of 1
APPLICATION FOR „: ,al
WORK IN RIGHT -OF -WAY (ROW) PERMIT
Development Engineering
13/25 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4/71 FAX: (503) 624 -0752
FOR STAFF USE ONLY
General Information:
Right -of -Way
Property Address /Location(s): 9365 SW VIEW TER Case No.: K DW Z.o12- 000%0
Receipt No.:
Date: $
*Applicant's Name: COMCAST Application Accepted By: Y;(..
Address: 14200 SW BRIGADOON CT Revised 314109
OR BEAVERTON, 97005 8.
City /State: BEA Zip: 2 � • � L 3c2' a '
Primary Contact: Randy Shields ( REQUIRED SUBMITTAL INFORMATION
Phone: 360 - 828 -3547 Fax:
Contractor's Name: FISK COMMUNICATIONS CONTRACTING Submit a scaled sketch of the
185632 2/24/2011
proposed work to be done
CCB# Expiration:
Address: 2705 NE 65th Ave
City/State: VANCOUVER, WA Zi 98661 Professional Engineered Plans are
360 -314 -4454 360 - 314 -4456 required for:
Phone: Fax:
4;44,0,,„ ,•c , • Street Widening
• Subdivision Infrastructure
Plans By: • Main tility line extension:
Address: 4We ✓ - S 4 All V
City/State: Zip: 5-.42' i1
Phone: Fax:
Description of work: Directional drill from the East side of
SW VIEW TER going West to property line, placing 2- schedule 80 pipe with CATV service wire, to provide CATV service
for 9365 SW VIEW TER
Estimated value of work (within the public right -of -way): $ $385.00
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 ❑ NO PI
If so, please specify (BUILDING PERMIT) case #:
S _ 4
*NOTE: Person specified as "Applicant" shall be designated "Permitee" and shall provide
financial assurance for the work.
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Issue Date lab a House R Address Pending Permit Commercial Node instructions
08/08/12 370357 9386 SW View Ter, 97224 No Yes No TOM toad Bore, 2 OW Bore, 2 SW Sot
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TRANSMISSION VERIFICATION REPORT
TIME : 09/1912012 10:46
NAME : CITY OF TIGARD
FAX : 5035981960
TEL : 5037182449
SER.# : BR0H7J690762
DATE,TIME 09119 10:46
FAX NO. /NAME 13603144456
DURATION 00:00:13
PAGE(S) 01
RESULT OK
MODE STANDARD
ECM
n
CITY Q1= TIGARD RECEIPT
IN � @ . 13125 SW Hall Blvd., Tigard OR 97223
503.639.4171 .
T J ARL7
Receipt Number: 188436 - 09/19/2012
•
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
R0W2012 -00080 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 104676 JFLOYD 09/19/2012 $300.00
Payor: Margaret Fisk
Total Payments: $300.00
Balance Due: $0.00
II
TRANSMISSION VERIFICATION REPORT
TIME : 09/19/2012 13:42
NAME : CITY OF TIGARD
FAX : 5035981960
TEL : 5037182449
SER.# : BROH7J690762
DATE,TIME 09/19 13:41
FAX NO. /NAME 13603144456
DURATION 00:00:44
PAGE(S) 05
RESULT OK
MODE STANDARD
ECM
•
CITY OF TIGARD RIGHT OF WAY PERMIT
` ail .'. COMMUNITY DEVELOPMENT Permit #: ROW2012.00080
T (GAP .D 13125 SW Hall Blvd„ Tigard OR 97223 503718.2427 Date Issued: 09/18!2012
Parcel: SEG1794
Jurisdiction: Tigard
site address:
Subdivision: Lot:
Project: Comcast
Project Description: Adjacent to 9365 SW View Terrace. Directional drill from the east side of SW View Terrace going west to
property line, placing 2" schedule 80 pipe with CATV service wire, to provide CATV service.
Owner: FEES
Description Date A m o u n t
ROW Permit Fee 09119/2012 $300.00
PHONE:
Contractor:
PHONE:
FAX:
Applicant:
RANDY SHIELDS
14200 SW BRIGADOON CT
BEAVERTON, OR 97005
PHONE: 360 -828 -3547
total 5300.00