15945 SW BRENTWOOD COURT-1 F?ILE NO. 2.12.2
BRENTWOOD PLACE 1.5945 STR. OPN. PERFIT
1
APPLICATION - STREET IMPR( -MENVEXCAWATiON COPY TO:
ORDIN,,,,CE NO. 74-14 ❑ (WHITE) -FILE
^❑ (IILUE) INSP.
(INST kUCTIONS ON SEPARATE SHEET) `J (YELLOW) •O'rHE;7 AGENCY
❑ (PINK) -APPLICAN'+
APPROVED I] APPLICATION NO.: --_
NOT APPROVED CITY OF 7IGARD, OREGON FEE AMT.: S
PENDING FEE. PMT. ❑ CdTY HALL RECEI£] O.:--, 77 3 _
FENDING SECURITY ❑ FUBLIC WORKS DEPARTMENT BY !` ___ DATE_
PENDING AGENCY "OK" ❑ Application and Progress Record
PENDING INFORMATION L.]
FOR STREET IMPROVEMENT/EXCAVATION MAIN SER QUIR ❑eONDI
ANNUAL
PENDING VARIANCE ❑ EXPIRATION DATE:
PERMIT NO.: DATE ISSUED: BY:
(1) APPLICATION IS HEREBY MADE. TO EXCAVATE FOR AND INSTALL
fAS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY PEQUIREMENTS.
ADPL CANT �._. t 11+� _._ �.L� `—�'�__ i 1y�trc11g.14r.s.�__-- kc_-�
NAME AD v J CIT J P ONE
CONTRACTOR—
PLANS
ONTRACTOR—
PLANS BY
NAME ADDRESS CITY — -PNONE —_
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): s
DOLLARS
(2) EXCAVATION DATA: FOR OFFICE USE:0.02 X S = s
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
kAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM A _QUANTITY
I 4.1 C t1{1J STREET -
OPIUR
IN� - — —
-- R I ON
EQu
ESTIMATED STRSET OPENING DATE: _� ! l(:� "V I {SSC _ g
ESTIMATED STREET CLOSING DATE: / g �-
--_-- --=._ --- --- - D
STREET
(3) SECURITY NO. `n?S-q -.� SECURITYAMT.: S 5`- CLOSED
SURETYCO.: _��rJ— N wY RN�.Q FINAL r l
CERTIFIED CHECK ❑ CASHI_❑ IOND INSPEC. -
(4) : LOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISI;;vS/CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTENT.
vv�1
IF
(5) NOTE THE CITY OF TIGARD DOES NOT, HERESY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RI;HT OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON.
THE AmPLICANT AGREES TO DEPOSIT 1 W PEQUIRED SECIIRITIES, TO COMPLY WITH ALL PERTINENT LHWS 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: -tib ,�� DATE��1�/�f l per•
CIrfOF TIGARD No. 3773
*� 12755 S.W. ASH yy
A4 P-0-BOX 23367 Date L:
TIGARD,OR 97223
Name
o,idriase
Lot Block/Map ;bdivision/Address
htlif 'a{:y Bldg., PlumbCash Check
Sewer Other _ Other Rec.
Acct. No. rAescription Amount
10.432 Building Permit Fees �-
10.431.600 Plumbing Permit Fees
10-431-601 Mechanical Permit Fees
10.230.501 State Bldg. Tax
10.433 Plans Check Fee
10.435 Other Licenses & Permits
30.443 Sewer Connection _
30-444 Sewer Ins section
24.448 Street ^ 'st. Dev. Charge
5-449-610 Parks I Syst. Dev. Charge
25.449.620 Parkn II Syst. Dev. Charge_
31.450 Storm Drainage Syst. Dev. Char e
:I°d x0430 ,.,s `-814h0e8e Tax
10.434 Alarm Permit
10.227 Bali
1G-455- Fines- TrafficlMlsdlParking
10 2x0- y CPTA TrafficlMisd/Vic. Asst.
10-456 Indigent Defense �-
4 _
30.446-401 Sewer Servl,;e/USA --
30.446402 Sewer Service/City --
31.447 Storm Drainage
40-475 Bancroft Prin. Pymt.
40-471 Bancroft Int, pymt. —'
10.451 0 her har es for Services
TOTAL
DEPT.