ROW2013-00031 City of Tigard
Application for Work in the Right -Of -Way
TIGARD ROW Permit
Property Address /Location(s): 12120 SW 72nd Av FOR STAFF USE ONLY
WR# 3380903 5EG933
Right-of-Way ,
Case No.: NO W2-03
*Applicant's Name: NW Natural 3 20
220 NW 2nd Av Application Accepted: By:
Address: Application Reviewed: 3 tZ 0 By:zejj
Portland OR
City/State: Zip: 97209
Judy Doblie $300.00 Application Fee Due: Yes ❑ No
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Primary Contact: y
503 - 226 -4211 X 4428 503 - 273 -4822 Applicant Notified: — L, n Phone: Fax:
Email: nwnpermits @nwnatural.com ,Q ei , It /e 3,2I Receipt No.:
REQUIRED SUBMITTAL
Contractor's Name: Same INFORMATION
CCB# Expiration: • Application form, completed and signed
Address: • Submit one (1) copy of scaled sketch of
City/State: Zip: the proposed work to be done
Phone: Fax:
• Submit one (1) copy of traffic control
Email: plan
Professional Engineered Plans are required
Plans By: for:
Address: • Street Widening
City/State: Zip: • Subdivision Infrastructure
Phone: Fax:
• Main utility line extension
Email: Lcugiln \masters \land use applications \ row app.docx Rev. 7/19/12
Description of work: Cut long side service off at main. Main on the 11' 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 ❑
If so, please specify (MLP, SDR, SUB, etc.) case #:
Is the work related to a BUILDING PERMIT? YES NO El
If so, please specify (BUILDING PERMIT) case #:
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Signature of Applicant /Permittee: °••�° °m�m.,wa m Date:
Print Name: Judy Doblie Ti 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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NW Natural PLAT: 1- 043 -022 COUNTY: WASHINGTON 03/20/13 08:36
USER ID: jkd
(503)226 -4211 TOWNSHIP: TO2S RANGE: R01 W SECTION: 1 NE SCALE: 1 IN = 100 FT