10676 SW COOK LANE FILE NO. Nl.�
COOK LN. - 10676 STR. OPN. PERMIT
APPLICATION - STREET IMPRC MENT/EXCAVATIONOPY TO:
ORDINANCE NO. 74.14 (WI-11T�)•FILE
(INSTRUCTIONS ON SEPARATE SHEET)
(P OTHER AGENCY
� )-APP'.ICANT
APPROVED Ki APPLICATION NO.. Z
_ ZCl
NOT APPROVED 11 CII Y 01 I IGARD, OREGON FEE AMT.: $
PENDING FEE PMT. ❑ CITY ti HALL RECEIPT N C
PENDING SECURITY 11 PUBL IC WORKS DEPA R TMENT BY — DATE Zn /ZZ /C.59
PENDING AGENCY -OK- [3AI)I lication and Progress Record _ — N—
PENDING INFORMATION ❑
FOR STREET IMPROVEMENT/EXCAVATION MAIASER QUI RED
E BOND M.
ANNUAL L;
PENDING VARIANCE ❑ EXPIRATIO DATE-
PERMIT
A E:PERMIT NO.. 347789_-_.__.______ , DATE ISSUED: __ i0111 89
-- ------. . B Y: __. --.-...-.._. ..
(I I APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL. A.C,_dri eway app h(sj_and
con*.cu .vert(s) _ AS DESCRIBED HEREIN, IN FULL ACCORDANCE WI fH CITY REQUIREMENTS.
APPLICANT Cl•✓ce_Joh_nson 10676 SW Cook Ln. Tigard, OR 97223 639-8005
W NAME - ----- --- ADDRESS
CONTRACTOR __.. NAME _. _- ADDRESS CITY - -.-__ ._ .PHONE_._.._
PLANS BY—_ City- Standards Sjecfications
N AMH ADDRESS --- CITE' --PHONE---------
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S
DOLLARS
(2) EXCAVATION DATA. FOR OFFICE USE: 'MIN.
_ 0.04 x s 300.00 f 12.00
STREET DESCRIPTION i PROGRESS & INSPECTION STATUS_
NAME SURFACE CUT CUTCUT MATERIAL INSTALL[D ITEM DATE REMARKS/TYPE�Y
TYPE LENGTH WIDTH DEPTH ITEM & QUANTITY
STREET
SW Cook Lane) alreadylinstalLed it E TION
—
Q
u
ESTIMA'►'Eb STREET OPENING DATE._._. / FE g
ESTIMATED STREET CLOSING, DATE: �. / / T
E
STREET
(3) SECURITY NO. - SECURITY AMT: S N%A_=_ CLOSE
SURETY CO.. __ __ -FINAL
n 1 �
CEHTIFIED CHECK CASN_❑ IOND INSOEC.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS:
FEATURES; EXCAVATION OCATION ANn EXTENT. 1. Call for inspection 639-4171 _
N 2- Repair or replace Culvert ends,
I 1 to eliminate broken pipe.
Correct culvert grade, to orovide
CURB - I _ ,! u1� _ _ for positive drainage.
3. Option: repair culvert endg on
Lane — _ - one "approach" and remove the
x __ _ _ _ _ _ other approach (the gravel
—_ `-� --- --- - I approach).
I �
I $I rE I
C IG�Ea'!fn 5.W CO k(LNy 1
(S) NOTE THE CITY OF TIGARD DOES NOT. HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT OF-WAV JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON.
THE .APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURITIES, TO COMPLY WITH ALL PERTINENT LAD'S AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
APPLICANTS SIGNATURE / I'll /�ry
DATE ��� I
TY OF:. T I-WAT.) PECE!F"T OF PAYMENT REC NO- (.0 1 Qtie,,
I�j
H A 12.nO
UTI .: ANOUNI
_
NAME C.i,.YDE J JOHNSON I , .)tjpjr,ll. 1. . (30
ADQRES�i 1 10676 SW %111M. LN PAYMENT OATF. : IL) .I1--(•:9
II 6.9-0&44
TWARD, OR'
PIJPPOE Or PAYMEW AMC)IJN'r I r) PI-)PPLISE. or 10UNT PAT
TMPP0VEM.*NT PI-PMJ7f:, 12. 00
S'TR'EET OPENING F'EJM.'T PXI. -'?.47-9!."
REQUEST FOR ACTION
C17YOF TIGARD
LOCATION _�C1 /_L.'
PROBLEM:
By: r -} 5 - -----�_ Date: _'_� --
�e
FORWARD TO: Administrator Police
P.W. OPERATIONS 4 _ Buildinq Finar. .a _—
M dce. M; ��� Library Recorder _--
..��Lam_
Plarnmg Other
Department Head Response: _ X r'�4 cc/ 70
Ne /1✓reGZS a rzrA",i,. rio 101-tQ / 10 10 C' 21--
i✓�cc✓s v ,s>-� c t y 'A Y�Cc .s He 5,4 r s
�o u.iorT-r'
BY:—W-,ble�-.3
ACTION TAKEN:
By: --- -- Date
WHITE:Return wireply CANARY:Follow-up PINK:Originator
4'
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Cui�tamer number- A 1, Status,.. RY Re adv
Resident' s name- JDHNSONI„ CLYDE Billing name:
Owner' s name: JOHNS30N,, CLYDE x
Attent ion name.-
Billing Address, (enter SAME in the number fi.P- A if samF--, as fretvireaddi--ess')
Nt..tmber Dir Street name TypE= Dir
10676 SW COM::' I N Additional address Line
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TTGARD, OR 77:127-1 -
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