11290 SW BULL MOUNTAIN ROAD-3 FILE NO.
BULL MTN ROAD - 11290 Si'R. OPN. PERMIT
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C11"I OF TIGARD
f_XPENDrIURE RHC UI S
Zhi.s form is a multi--use form. Appropriate receipts mist be attache. Documentation
is invortrnt for all purposes. Staple documentation to form.
VENDOR NO.: 1 DATE: - Z -9
PAYABLE '110: .iia eIr Ft IA W M ut e. L , _ RDQUty^I'ID BY: -
--- _EQ. 2 4
Approved request due Wednesday
10:00 AM to A/P for checks by
Friday.
EXPEND17URES:
Date Description, Ir 4nice No., etc. Account No. Amot.mt
0C) *'�'
404-91
Tom
Mileage $0.255
APPRDPRIATION BAIANCE: AS OF: ——_ SIGNATURF,:
(Up to $2.5.00) Section Manages- _` __� Purc h. Agent _
($25.01-2,500.00) Division Manager
($2.500.01--7,500.00) Dept. Bead
($7,500.01-15,000.00) City Administrator
($15,000.01- ?) Local Contract peview noard
ke/1501F
OWTATION Power Plumbing Co.
TO __-- _ r I.y _ - 244-1900
FAX:297.3941---5*
- - --- NO. _
JOB C DATE
_ \ ``
IEM
NO aTv DESCRIPTION OF MATERIAL UNIT OISC TOTAt S
PRICE
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APPLICATION - STREET IMPRC`,,� '}MENT/EXCAVATION COPY TO.
OR DI N, E NO. 74-14 (WHITE)-FILE
(YELLOW)-INSP.
(INSTRUCTIONS ON SEPARATE SHEET) (PINK)•OTHER AGENCY
(SLUE)-APPLICANT
APPROVED
NOT APPROVED [) CITY OF 'tIGARD,UREGON APPLICATION NO.: �`t _
FEC AMT.: IS 3Z
PENDING FEE. PMT. ❑ CITY HALL c1►- z�Qui
RECEIPT NO.:
PENDING SECURITY ❑ PUBLICWORKSDEPARTMENT BY r•TE- /
PENDING AGENCY "OK" C Application and Progress Record - - - - _ - - - - - - L
PENDING INFORMATION Cl FOR STREET IMPROVEMENT/EXCAVATION RED
PENDING VARIANCE ❑ "VN 'AI-
EXPIRAATI`ON DATE: -------
P
PERMIT NO DA fE ISSUFn: . �'J `l�_- BY
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL .ie.��[_
— nu.+�.� - AR DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT � P•' s� L� 1'� �-�C clT Q �y
NAME DDRFSS --�3`�- `14X1
C1 PHO E
CONTRACTOR_�cA v,r.t� SSS_- �,C . ,E, t Vu,QZ IAC ,y U
NAME ADDR ESQ— C*�—
PLANS F�Y._� _
CITY --PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST: Z nl�. °c^
_--,__..—..�--�z-_—s_— DOLLAR S
D
(Z) EXCAVATION ATA? tT CE iE: MIN.
STREET DESCRIPTION ESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSLENGTH WIDTH DEPTH ITEM & QUDATE REMARKS/TYPE BY
ESTIMATEr)STREET OPENING DATE. 1 ] y IESTIMATED STREET CLOSING DATE: .3 / Z '4 / .j _
E
(3) SECURITY NO — ��`�' sTREET c
---- SECURITY AMT.: :�_ CLOSED
SURETY CO.: FINAL Z
CASH ❑ •OVb INSPEC. L �(..�
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL
FEATURES; EXCAVATION LOCATION AND EXTENT. 1� � SPE<IA i VROVI410N9/CONDITIONS
itr SyZ Z /x_,J{!21 A 17 I
1 ( $ \11 1 I K ) 4 -"T
i 1 Sir►' 4Ht
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I5i NOTE ?HE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISRION TO APPLICANTS TO CONDUCT WORK WHE.1E
RIGHT-OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON.
THE APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURITIES, TO COMPLY WITH ALL PERTINENT LAWS 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 SIGNATUREI/
DATE
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CKJOTATION 'lower Plumbing Co.
TO z44-1900
FAX:297-3941----5*
NO.
DATE cr I
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DESCRIPTION Of MATERIAL PRICE
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QUOTATION 'Ower Plumbing Co.
TO244-1900
FAX:297.3941---5*
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rLEBoPower Plumbing Co. y �
244-1000
FAX:297-3941---5*
RESIDENTIAL--COIkAMERCIAL
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SERVICE- REMODEL
Richards P.O.Box 231d4
censed,Bonded&Insured Tigard,OR 97223
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