ROW2012-00048 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
'PI
• I' Request Permit Action
i i , , , i i , 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard- or.gov
TO: CITY OF TIGARD V 0 ,I D
Building Division Services Supervisor
13125 SW Hall Blvd., Tigard, OR 97223 /Q //L
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ' Applicant ❑ Contractor El City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual) /j ) VI �/
Mailing Address:
City /State /Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
Xf , CANCE VOID ERMIT APPLICATION.
❑ REFUND - - ' IT 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 canel pe "t).
Permit #: Fou_?
Site Address or Parcel #: / 7 w/ 10 /V,7 A
_C
Project Name:
Subdivision Name: Lot #:
/
EXPLA ATION: /J / " ' , / ' / i, /- .4.. 4d z "A
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/ i /' • �/ r �� r / ■ r� ..e44 I
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Signature: A Date: I ? . /. -
Print Name: / if
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b) not more than 80% of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.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.
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 Admire: Date By Rte to Admire: Date / Z / Z By ..,'— .
Refund Processed: Date #L/ /ff' By Invoice Processed: Date By
Permit Canceled: Date /p /Z /jZ By Parcel Tag Added: Date By
Receipt # Date Method Amount $
I:\ Building \Forms \RegPermitAction.doc Rev 05/25/2012
05/0g/2012 01:32 5037195475 TEXSTAR ENTERPRISES PAGE 02/04 s
APPLICATION FOR •
WORK IN RIGHT -OF -WAY (ROW) PERMIT i ■
TWARD
Development Engineering
13125 SW Hall Blvd., Tigard. OR 97223 (503) 639 -4171 FAX. (503) 624 -0752
FOR STAFF USE ONLY
General Information: F Right -of -Way •
Property Address/Location(s):
I x .1.`-1 4 I i.) �� Uzi-06 4 Case No.: ( .t� 0 - DD tf $
•
Receipt No.:
Date: 5-1-1.R
*Applicant's me: / '4 `1 Application Accepted By:
•
Address: Z es t) S ��
Name: � 0ACO. Co t ` e -^ .* j Rr.i,ed 3/4109 }' 5 , I 1 Z $ 3 a op
City /State: ae -akte. r'�Ovt ( O R. . Zip: q'- 66 S _
Primary Contact: �3.A" t as r _ REQUIRED SUBMITTAL IN
1.
Phone: 5-1) Z -3 i" 2 -(3 g 9 Fax: co^ - 3 T 2-al-- I
I
— 71--e-)g54 - 04 - (Ac Ja Submit a scaled sketch of the
Contractor's Name: : proposed, work to be done
CCB# Pi? ?'Q re Expiration: I0 -10 - 2d1S
Address: 0 _ Iv • -
d� Zi p: q 2 Professional Engineered Plans are
City/State: �oT 1 required for:
Phone: �- (t - S 3 — Fax: So --7/ - . '1 4 � _
• Street Widening
• Subdivision Infrastructure
Plans By; 6 r E4ttl, 5 fe 4-^� 1 - • Main utility line � . / 0
Address: 24'5 Aj r RJ (h S4- q�� A/ (ACA" /4► 4 I
City /State: c C ( 47 12- Zip: Q r
Phone. Co 3 - 94 c r - 6 j Fax: ..S - � •S-a4 - GiG11 �/ d � u p��J�7 3
Description of work: ■ P■e, -ta► elcsi e- i a uvt co. r?�
I tai, (e-- 4+ (2 am k.) A au ,, L. a 'Sv:
Estimated value of work (within the public right -of -way): $ l g 1-5 • 17
Is work related to a LAND -USE DECISION? YES ❑ NO 4
If so, please specify (MLP, SDR, SUB, etc.) case #:
Is the work related to a BUILDING PERMIT? YES I NO ki-
If so, please specify (BUILDING PERMIT) case #:
i *NOTE: Person specified as "Applicant" shall be designated "Permitee" and shall provide
financial assurance for the work.
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- . Diversion into a Continuous
4.430 Diversion into a Continuous Left Turn Lane 2 -Way Left Turn Lane
Diagram 430 .......
AHEAD l m
Diagram No. 430 shows work in the travel lane(s) next to a continuous _ N
two -way left turn lane with one direction of traffic diverted into the continuous B I fi •
two-way left turn lane, 1 h S ,2 1. Use truck- mounted high- intensity rotating, flashing, oscillating, or strobe -,,,; • ) I „'
warning lights with 360° visibility on all work vehicles. For added - ,. tANE ;
visibility, truck mounted arrow panels or PCM,S in the caution mode may - .. \ \;n' .
be used. A m
2. When two or more travel lanes are reduced to a single lane before the . .- • l
diversion, each lane shall be closed separately. A longitudinal distance _-
equal to 2L is required between each lane closure. I •
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3. A shifting taper (U2) may be added in the diverted traffic direction across - L/2 I • I
Posted sign
the continuous 2 -way left turn lane (as shown). This option is • speed sot,acx, Boon«
recommended when the speed is 45 mph or greater. _ r {rnptia A B
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or less 100 10D too
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4. When protection vehicles are used and the speed is 45 mph or greater, 35 • a 350 360 250
use of a TMA on the protection vehicle is recommended. - Y.' as • ss 500 500 350
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Diag No. 430 I E . •'
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