8905 SW BURNHAM STREET-1 FILE NO. _WZ]g
BURNHAM ST. - 8905 STR. OPN. PERMIT
CITY 0:' TIGARD-12420 21V ' IN,TIGARD—OREGON 97223
ItECFLPT JRt+
DATF: �7� — AMUUNT: -
_ DOLLARS
N'A;�,G:- KI , _ CASH:
AU;)?iiSS: D
15 4 :�L 3 7S
OF
^OR: ACCT.# PERMITS SURCHARGE AMOUNT
SEWER BILLINGS 10-131 $
r
BU`IINESS LICENSE 05-331
PLUMBING PERMIT 05-332 •
MECHANICAL. PERMIT 05-332
BUILDING PERMIT 05-333
SEWER CONNECTION 10-363 _
SEWER INSPECTION 10-365 _
SYSTEM DEV. CHARGE 40-366 _
PARK DEV. CHARGE #1 45-367
i
PARK DEV. CHARGE #2 45-368
0NINC ADJUSTMENTS 05-362
TOTALS
RECEIVED BY:
PI:RIlIT NUMBi?LS ASS. GNEU:
Number Amount Number Amount Number Amount
$ $------
_ $
�— 3— Ll, 'i' 4i 4
APPLICA PION - STREEI IMPP EMENT/EXCAVATION COPY TO:
(WHITE) FILE
ORDINANCE NO. 74-14 ❑
r❑r, (BLUE) -INSP.
INSTRUCTIONS ON SEPARATE SHEET ( A -OTHER A--.ENC,
( I D (PPINKK)) -APPLIC.ANT
APPROVED Fx. APPLICATION NO.: 6 7
NOT APPROVED ❑ (111' 01 1 IGARU, OREGON FEE AMT.: S 2-, Ey) —_—
PENDING FEE PMT. ❑ CI Y IIALL RECEIPT fyl0.: .
PFNDINCG SECURITY ClPUBL.ICWORKS DEPARTMENT By
UATE
PENDING AGCNCY ''OK" ❑ Application and Progress RCCOf(1 — • — — — — — — — — — — —
MAINTENANCE BOND M
cHld-
PENDING INFORMATION ❑
FOR STREET IMPROVEMENT/EXCAVATION ns REQUIRED ❑
..YNUAL ❑
PENDING VARIANCE 11 EXPIRATIE f
PERMIT NO. (e' L- DATE ISSUED: _ _1_ !_ BY t �'---_-- -
( I) APPLICATION IS HEREBY MADE TO EXCAVATE Ir 012 AND INSTALLbtil�IJA(R L1gTLA
(�-% Vl t:s_,IIa)- IWAIN AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT ---SLR.' �t`{ --- •(��, 'i�Irr�hrszilL — — 3YL
NAME
AD.�4 IT HONE
CONTRACTOR �. 7
T,
NAME ADDRESS -- -------- PHONE ---
PLANS BY — ...��� _
- - --_ NAME ADURf.SS ` �, CITY PHONE----
ESTIMATFD IMPROVEMENT TOTAL VALUATION ( COST): $
DOLLARS
FOR OFFICE SE: N
(2) EXCAVATION DATA: 0.02 X S '' t
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
—
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE I BY
TYPE LENGTH WIDTH DEPTH ITEM AI QUANTITY�tr•l, 1 ! i STREET
1't F'• ---
OPLNED
INSPEC- ----
R TION
E — _
Q
— _ U — ---
ESTIMATED STREET OPENING DATE: .� / / g `-
ESTIMATED STREET CLOSING DATE: �L / E
(3) SECURITY NUTREET
_ SECURITY AMT.: : � U' �I CLOSED - -
—..
SURETY CO 6"A — z FINAL 7 7
CERTIFIED CHECK ❑ CASM BOND a INSPEC. J -/
(4) PLOT PLAN. INDICATE SITE PERTINENT PHYSICAL u�- SPECIAL PROVISIONS /CONDITIONS:
FEATURES: EXCAVATION LOCATION AND EXTENT.
1 I I 1
CUR 3
I /01 I -
OFFIG�� I
(5) NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
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 ORD MAC�Fj WHICH MAY RESULT FROM APPLICANTS AC'rIOI4S.
7
APPLICANTS SIGNATURE: DATE
1• king r,.. ,• �M.; TIGARD BRANC - `^"�
M � . �.r. or` ori
. C.AFID'` TIGARD.OREGON 9722
,._,.P.O.Sox22788 "/� TIGAFiD,ORE.9722`7� ".
1:ham, y, ;
'd Td
1230
aw. M -` �r,`r,. DAT[i �,��,:. AMOUNTv'"i
+a
Oity of Tigard w �. 1-24-78-z
340ri�'y���Yy
ond
:,� ��., `h.w�.,�„r,ry„�'�., „+�F ._ r'v�,."_�• .��-^ •.yr l _ ..,�,r• "ate,• "r
� ...,,���1'�ry�ryrr + ..•'V+•W.. � X1••1,...
25111[ m�■.�.G..3t
n
.1�1O 1,91• JI.I ■ 10.7 59��R •w`,,.•.. -,"�.,,,,. '.a'`. w`I',w, •,�+rr� "+.
•.�`, }rt``'e~ '�.r- 'r.", •. Y.
AIR-KING NANUF'ACTIJ t`INC C�7. rwr ^T ^. DETACHa "1cDINRi►YMItHT circ rrSrrA,T oirEcmirc •rt_c�w. T ...
1•' iI NOT.CPROW=PI,ryr NOTIry Ur r•ONrTl.Y. NO Art.rlr O["I.Wo w v"'� ~,••`ti
•"'� - _ D[LUX[-FORM TWYD-3 SPLI151.7
•r��NVOIOt D9823 R0•T 1 O N - .•AMOUNT .. DIMOUNT' ,OTN[RDIfT111RUTION
Nwr AMOIJNT`
✓M,. `• ` AOOT. N0. AMOUNT
n 1 _ AOO. PAY .._
444-:78 Refundable fond ^CCS
...-�.'�. I PAYROLL-
7
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