11995 SW KATHERINE STREET FILE
KATHERINE ST. - 11995 STR. OPN. PERMIT
APPLICATION -- ,STREET IMPRr '=MENT/EXCAV NTIONCOPY TO:
:&(WHITE) .FILE
ORDIN,...CE NO. 74-14 (BLUE) -INSP.
INSRUCTIONS ON SEPARATE SHEET ❑ I,ELLOW)• ICAN A/.IHC�
(INS- 1 �(,pINK)•/A�FPLICAN
APPROVED ,[ APPLICATION NO.: / •'� -`
P407 APPROVED I] CITY Y OI' I IGARU, OREGON FEE AMT, S.—
PENDING
.PENDING FEE. PMT. [] CITY HALL RECEIPT NO.:
PENDING SECURITY
❑ PUBLIC WORKS DEPARTMENT BY -_.t�L. DATE
PLNIIING AGENCY 'OK" ❑ Application and Progress Record + ,
MAINTENANCE F,ONM Sc
PENDING INFORMATION ElFOR STREET IMPROVEMENT/EXCAVATION AS REQUIRED
ANNUAL ❑
PENDING VARIANCE ❑ EXPIRATION DATE: ����
PERMIT NO.: ( .. DATE ISSUED: .��—_L_ , BY: -----_.
(1 ) APPLICATION IS HEREBY MADE 10 EXCAVATE FOR AND INSTALLlz
_ AS DESCRIBED HEREIN, IN FULL_ ACCORDANCE WIT►, REQUIREMENTS.
APPLICANT V' # -..:S)_ L�1�C �- �I SS_1.� .A JI'✓1:- -a - {'7�/�4O
NAME ADDRESS I -_-_._.--_ PI'IOIVE __.—
CONTRACTOR -�-` n e,
-
N/'M[m_._.-�.___-- -
PLANS BY _ -- --5-A kM
NAME !^ TADDRESO -'� CITY PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S
(2) EXCAVATION DATA: FOR 0►wICE USE: C-�iL� UMIN.
0.02 XS
STREET DESCRIPTION _ PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUl CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
KALA
TYPE LENGTH WIDTH DEPTH ITEM A QUANTITY
fi/! I s _n ) .�t1, 1�VrI aTREETOPENED
E ----- -.
Q
Ef;TIMATED STREET OPENING DATE:_____ ._ �_ ET --- —
ESTIMATED STREET CLOSING DATE. �__� - � 7 E
(3) SECURITY NO. SECURITY AMT: :.-�_ _� _ CTREET _
SURF TY CO FINAL
CENII FIEU CHECK U CASH ❑ RUN= NSPEC.
(4) PLOT Pi AN: INDICATE SITE PERTINENT PHYSICAL S.`ECIAL PROVISIONS /CONDITIONS!
FEATURES; EXCAVATION LOCATION AND EXTENT.
I
I I 1 1
I I I I 1
S NOTE: THE CITU OF TIGARD DOES NST, HERtFBY, GRANT� ���_.___-_ _���'�----_•--` -
( ) PERIAISSION TO APPLICANTS TO CONDUCT WORK WHERF.
RIGHT-OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNTY 13R THE •,TATE OF OREGON
THE APPLICANT' AGREES TO DEPOSIT THE REQUIRED 8E1:.UR171ES, TO COMPLY WITH ALL PERTINENT LAVIS AND
CONSTRUCTION SPECIFtCATIOUS PERTINENT TO CONu, ;%;T OF TH? WORK, AND TO SAVE HARMLES0, THF CITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FftOM APPLICANTS ACTIONS.
APPLICANTS SIGNATURE: re! 't t L ` ._- i/., DATE J (2-
------ 4
CIT V OF TIGARD—12420 S.W.MAIN—TIGARD,OREGON 97223 - - ---••- --
RECEIPT Sr
DATE:. -I---- --`MOUNT: $
--DOLLARS
NAME:
NAME: 'ASH: '
CHECK• _ -T---
ADDRESS:
_ M.O.: .---..
I OF
FOR: ACCT. f PERMITS SURCHARGE —_AMOUNT
CL%WER BILLINGS 40-364
BUSINESS LICENSE 05-531 — -
PLUMBING P RMIT 05-332 _ S ---
MECHANICAL PERMIT 05-332 ---- - -
Bl"LDING PERMIT 05-333 ----
SEWER CONNrCTION 40-363 —
SEWER INSPECTION 40-365 _-
SYSTEM LkV.CHARGE 25-366 _
PARK DFV.CHARGF #1 30-367 --
L
PARK DEV.Ci4ARGE #2 30-368 —. -_ — --- -
ZONING ADJUSTMENTS 05-362 --
_
TOTALS ,
RECEIVE
PEPMIT t SERS AtSIFNED: �,f
Numbs �mrant I Nun ber Amount I Number - Amount i'