8950 SW BURNHAM STREET FILE NO. STR. OPN. PERMIT
BURNHAM ST. - 8950
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City of Tigard
INSPECTION REQUEST
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INSPECTION TIME : :HERMIT NO.:
I DATE: 3 /6 / 1 L DATE ISSUED: _.L-Z--
OWNERS NAME : b --+-
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ADDRESS : _, -.�,-
CONTRACTOR :._ �' -�' �^�•` 11 —
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RESULT. App►oved;Si , Disapproved U , Pending ►-]
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I INSP C OR DATE
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APPLICATION - STREET IMPR' tiMENT/EXCAVATIJN COPY TO:
l.j IWHITEI-FILE
ORDIN. ..+CE NO. 74-14 ❑ (I]LUE) INSP
INSTRUCTIONS ON SEPARATE SHI: T E) (YELLOW)- HER AGENCY
( Ir � ❑ (PINK) - APPLICANT
APPROVED Its., APPLICATION NO.: .�.
NOTAPPROVED �—�
CITY Of T'IGARD, OREGON `w --=-
' ❑ FEE AMT.: E_�— -----
PENDING FEE, PMT. 11 /
CITY HALL RECEIPT NO.: __ / 404SS
PENDING SECURITY 0 PUBLIC WORKS DEPA R TMEN T BY A—� DATE. _ 22 L `1
PENDING AGENCY ''OK'' ❑ Application and Progress Record
FOR STREET IMPROVEMENT/EXCAVATION MAINTENANCE BOND
PENDING INFORMATION ❑ Al REQUIRED
ANNUAL �
PENDING VARIANCE ❑ EXPIRATION DATE:
PERMIT NO.: 77 _ DATE ISSUED: 77 , BY:
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
n .� AS DESCRIBED HEREIN, IN FULL ACCOR'D/ANCE WITH CITY REQUIREMENTS.
APPLICANT r i�rf F rl! 111 7-/ 15i'.� /.> /�-'GcLL',FZ--P --- _ -6_3 9- X27 L
A v ADDRESS CITY PHONE
CONTRACTOR
A- Ap Tj� CITY PHONE
PLANS BY `:>09r11 4o /9SA'156,41111 PHONE I —_ ------ -- --
NAME �� A J�J!' CITY PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S
„! •�L ___-.
DOLLARS
WFOR OFFICE
(2) EXCAVATION DATA: 0.02 x s •3`+_-
STREET DESCRIPTION _ PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL IHSTALLED ITEM DATE REMARKS/TYPE I BY
TYPE LENGTH WIDTH DEPTH ITEM 8 QUANTITY
F�t 1rll_ >(. , d J rG– STREETKMLD
jt 1 N
ESTIMATED STREET OPENING DATE:-� / -717 S
ESTIMATED STREET CLOSING DATE: E
D
(3) SECURITY NO. SECURITY AMT.: S_— CLOSET
SURETY CO.: «•37 �r rl FINAL
CERTIFIED CHECK IJ CASH O SONO o INSPEC.
(4) PLOT PLAN INDICATE SITE PERTINENT PHYSICAL ----� SPECIAL PROVISIONS /CONDITIONS:
FEATURES: EXCAVATION LOCATION AND EXTENT.
El '
(5) NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSIONTOAPPLICANTS TO CONDUCT WORK WHERE
FIGHT OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON,
THE APPLICANT AGREES TO DEPOSITTHE REQUIRED SECURITIES, TO COMPLY WITH ALL PERTINENT LAWS AND
CONS(RUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGI W141CH MAY RESULT FROM APPLICANTS ACTIONS
/ �1,! 14
APPLICANTS SIGNATURE DATE
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CITY OFTIGARD
Date ` Amount
dollars '
Name P _ _ Cas
M.O.
Address 1 0-0, I ag Check
Bldy. F'� St.ORn0, Bus.Lic. —
P16g. - Pu6ctns. - [] Bike Lic.
Elctl, El Copies El Sew.Serv. -
Sewer - E] Filing Fine&F.
Assmt. - Other Zoning
for.
Permit
CITY F TIGARD
By:
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