12387 SW KNOLL DRIVE-1 FELE NO. 529-92
KNOLL DIVE - 12387 ETR OPN PERMIT
I
ENGINEERING PERMIT
PERMIT #. . . . . . . : ENG92-0088 DATE IS` UED: 12'10/92 By: _
PRIM. PERMIT #. : MLP92-0007
SITE ADDRESS. . . : 12387 SW KNOLL DR PARCEL: 2S101BC-01400
SUBDIVISION. . . . : KNOLL ACRES ZONING: R-4 .5
BLOCK. . . . . . . . . . . LOT. . . . . . . . . . . . . :5
PERMIT TYPE. . : SOP PUBLIC IN!PRV QUANT. (LIN FT) VALUE
AGREEMENT DATE: / / GRAD/EROS _ rk*- $
ASSUPANCE EXPIRATION--- STREET " $
F ;FORMANCE: / / SAN SEW " $
MAINTENANCE: / / STM FFW " $
PATFi:JAYS _—�—_ " $
ALL OTHER ***- $
TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Remarks: STREET OPENING, TO INSTALL OR EX'PI:ND A BUILDING SIDE SERVICE (SAN)
LATERAL.
Permittee: _._. ----------•---- FEES ----------'-----
FOUR D CONSTRUCTION COMPANY type amoult by date recpt
P.O. BOX 1577 01'E.:N $ 0 .00 JSH 12/10/92 92-234.571
BEAVERTON OR 970-75
Phone #: X503) 641-0935
Engineer:
$ 8 .00 TOTAL
Phone #:
------- REQUIRED INSPECTIONS ---- '----
Permittee/Agent Sicnature: ---SZ'i);2M SEWER-- - ----STREET---
M.H. & C.B. CRB TINE & GRADE
PIPE_ LN ;; GRD '3UBC-RADE
BCK.FL;, & CMPCT BAS r ROCK
AIP. li TV TEST LL: EL COURSE
City of Tigard, Oregon VEA1<IN�:, COURSE
13125 S.W. Hall Blvd. - --^ii1'7. SEWEP--- T?^ ;F & PED CONT
P.O. Box 23397 M.H. & .C' . Mit :'MENTATION
Tigard, Oregon 97223 PIPE LN !; GRD S'..aEETLIGHTING
Phcne #: 539-4171 BCKFLL & CMP^'P V7E,LK/APRON/RAMP
AIR & TV TEST
FOR INSPECTION, CONTACT: •- -•--GRADING-----
Letha Thomas #639-4171 (office) --RE11R1 ;3,'ADJ,S-- %,0VTOURS
#780-2647 (mobile) 0;:AINAGE
----PA7 HWAY;;--- EiROSION CNTL.
APPLICATION -- STREF_T IMPRO"If MENIVEXI-AVATION COPY TO:
(WHITE)-FILE
OR DIN A �I�E NO. 74 14 R (YELLOW)-INSP
(INSTP'!-TION£. ON SEPARATE SiHEET) (PINK)-OTHER AGENCYb],(3g
(BLUE)-APPLICANT
APPROVED j� APt'LICATION NO. 5i14-
'JOT
-'JOT APPROVED (_J (;I I Y O I IGARU, OREGON F'F.0 AMT. 5 8.0
PENDING Ft E PMT. ❑ C1111' HALL RECEI ,NO.: 9-Z.. -Z_S4S. 71
PENDING ;ECURITY U PUBLIC WORK'S DEPARTMENT BY DATE I L IO / q7-PENDING AGENCY ''OK" ❑ Appli(mion and Progress Record _ - - - - - - _ - - - _
MAINTENANCE BOND it
PENDING INFORMATION ❑ FOR STREET IMPROvEvw/EXCAVATION AS RFQUiREIP
A/JN'.AL
PENDING VARIANCE ❑ EXPIRA ION DATL:�
PERMIT NO.: .__ DAT S Z. c i r ,--
_ ISSUED: --- I0 �9Z BY
(1) APPLICATI N IS HEREBY MADE TO EXCAVATE FOR AND INSTRr�Y A BUILDI SAN. EWER SERVICE
LATERAL (dl{� - .L,�_1���'AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT _ FOUR D CONSTRUCTION _-P-0. BOX 1577_-_ _ BEAVERTON,_OR_ 7 7�T641_093
NAME - ADDRESS CIT PHONE
CONTRACTOR-----(SAME)
__
NAME �---- �ADORE54 CITY
PLANS BY _ PER CITY STANDARDS_AND SPECIFICATION3 -
W-- NAME ADDRESS— v CITY ---_. PHONIE�---
ESTIMATED IMPROVE MENT TOTAL VALUATION ( COST): S � 200.00
DOLLARS
(2) EXCAVATION DATA: POR MIN
0.04 x s�DD•OQ__
STREET _ DESCRIPTION PROGRESS_& INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM !')ATE REMARKS/TYPE BY
TYP_F_ LENGTH WIDTH DEPTH ITEM_— AI QUANTITY
STREET
PEN
C-
KNOLL DRIVE ----- -}-- INSv[
(SEE A'I'TAC D) _ _ R TION rS
Q
ESTIMATED STREFT OPENING DATE: _L_—� S
ESTIMA rED STREET CLOSING DATE: I (
T
(3) SECURITY NO. __- SECURITY AMT.: $ STREE
_ 2QU.00 __. CLOSED
SURETY CO : - FINAL
—. - INSPEC. IT. Zai r L,
crRIIrIEI! [HeLH CASH0 BOND ' .
(4) PLOT PLAN. INDICATE SITE PERTINENT PHYSICAL - SPECIAL ProvISIONS CONDITIONS
FEATURES; EXCAVATION LOCATION AND EXTENT.
.- Notifyins�.e.�_to�.C•�.lifla�'�1Uina�_—
(639-417] ) 24 hrs. bef(,)Ye starting
i 1 wA11-. auk
' a I 1 standards & specifications.
K•w ---URS --
l o. pre-
---no i f i . io_.�:� ies.
_ Traffic control must be prov?.dcd
S. W. KNOLL DRIVE w
_ -- ---.__—__ oriy- t epi contractor.
3 -a}► X I _ w - for 1,., rent rar _
1 4' The roadway shall not be closes
( i Work are I I ti - t'�resagtf ttafftz' t any-t1m '
I
SITE: 12387 S.W. I I I I -`A a -regUtred---
Knol l Drive -at.Jho-end Pacl1 daY�—_---`-
_-_. _ .. Conditions of-&P 92-0007 apply.
I5I NOTE THE CITY OF TIGARD DOES NOT. HEREBY, GRANT PERMISSION TC 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 COMPL- WITH ALL PERT;NENT LAWS AND
CONSTRUCTI()N SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORY., AF:G TO SAVE HARMLESS THE CITY AND
EMPLOYEES A3AINST ANY INJURY OR DAMAGE WHICH MAY RESULT FFFf'ti APPLICANTS ACTIOI/S.
APPLICANTS SIGNATURE L 1
DATE
: ov.
12f
4 qCe I C)
12 0
17k`2 /
I?': .A 2244 12242 I Ih u I /moi
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SEE MAF' '✓�� n WASLiINGTON
2S I ICiE � � I � 1 � 1 INITIAL POINT SCAM
IKNOL.L ACRE`. GEO�
be r se0°24'E
N e00 25' �5�.1e —
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600 N 400 301 wT
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2,09AC. D.L C
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it
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I 11 457._ 27 J491' \ (C.5•No.{2029)
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S e 'E 1lN67aIJ'{y ` ae /p N67!'IJk
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800 I 1400 �i6,a
f� �\1 (° I I �;. 1l��;� �'J 1500 zea 27 _ I
3 �. �. �n t� F. i? i 5AC
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900 U (GS.14o12033) K160-07
° d `s �'sa
a (" r'` r" n �" INITIAL. {�fh1Y
MAI' ° r-� _ _ I T13ARDIA TERRAC
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0 6 1000to 66.1 )
1200
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{n ,� : lu 800
e Jr 1801
~ ui1900
O �-- � :,=� .�. 660 a j,�i } M J r...., 4 � J �r ) � M�
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23 -74
h
N
SEE MAP ,� 2401 ?�
2S 1 2.AD 3.51 Ac.
r
I
• I
_ I
BUILDING SEWER PIPE, SIZE AS SPECIFIED 1
PLANT FABRICATED TEF FITTING
ON SEWERS 19" AND SMALLER. BACKFILL 2X4
FIELD TAP ON EXISTING SEWERS AGAINST PWG TO
AND NEW SEWERS LARGER THAN PREVENT PLUG
THAN 18". 1 BLOWOFF fA SEC )RE
2X4 IN PLACE VITH
/TRENCH BACKFILL
'-SEWER MAIN PLAN.OR L-ATERAL I
I
EXTEND AT LEAST
GROUND 12"ABOVE SURFACE
SURFACE
MINIMUM SLOPE FOR
6" PIPE: 0.010, FOR
4"PIPE : 0.020. 9WlCE CONNECTION
MARKER :
MAGNETIC TAPE—s
GREEN ./B LACK LETTERS (WASTE WATER)
GREEN R/BLACK LETTERS (STORM DRAIN)
_PLUG
r•. 3/4"-0 PIPE ZONE MATERIAL
IL
• SUPPORT TEE WITH As SPECIFIED
REDWING GRAVEL, S I DE
MRILMUY 2,C" WIOf
BUILDING SEWER
Uf�>~d 3swKs A4«�r
or wad+{ngton
Dwg. No. 300
i
1 • • / PVC SADDLE (TEE)
I Imo/
STRAP kETAI "LA RIDOES I
1 I = -- RUBBER GASKET
_ - - --,
SEWER PIPE
i
` STA:`L=SS STEEL STRAP
■ PVI; SADDLE SHALL BE ASTM 3034 SDR 3S
w PVC; COMPOUNDS SHALL BE ASTM DIT84 WITH CELL CLASS OF 12454-B/C
OR 12364-C
■ ALL ELASTOMERIC SEALS (RUBBER GASKETS) SHALL BE ASTM F477
■ STAINLESS STEEL BANDS SHALL BE 300 SERIES, FULL 9/16" WIDTH BAND,
5/16' SHOULDERED HEX HEAD, SLOTTED SCREW AND IS CADIUM PLATED,
CARBON STEEL.
I NS'JRT I ON HOLE SHALL BE CORE DRILLED.
PVC CASKETED unified
SADDLE a"m
DRAWING 350
inns
r
I . COMPLETE RUBBER SLEEVE (ASTM 'C-443)
INCLUDES A MOLDED SEGMENT THAT HOLDS
IT IN PLACE.
2. STAINLESS STEEL BAND (9! 16" SERIES 300)
_ mull SECURES UPPER HALF OF RU89ER SLEEVE 7C 7HE
PVC HUB.
3. PV(; HUB (ASTM 3034 SDR 35)
DRIVE 114TO CENTER OF RUBBER
SLEEVE AFTER SLEEVE IS PLACED
IN HOLE.
I
2
,CONCRETE PIPE
�lI.1L�1.111�Z11.�i
NOTE; ALL INSERTA-TEE HOLES SHALL BE MACHINE DRILLED.
r �, unified
I NSER �i A - TEEQoagency
DRAW I NG NO._360 _
MIN. 3" A G 114 2 LIFTS
STREET AREAS I OUT OF STREET AREAS
6A;A.1 Cur
EXISTING L
LIS ECT17N RESURFACING
• ~ ',
OF
B 6. ,
. o• • • • •• / CLASS A
• • BACKFILL
• v
.LASS B U
J/4=G GRANULAR
.BACKFILL - O
\ , n-
v •,v•, , W
cl
lij
W - -o .4
AL1 O
ui
o.
Q aN •��J �'e ,
ZS. . o ,4 �. •o
e �
W '7 a ,•A •� o
PIPE BASF
BACKFILL IN STREET AREAS
IcS/W 13 AQAINST CURB, FILL ROC , TO
BACK OF S/W
2.Ir S/W IS NOT AGAINST CURB, FILL ROCK
2'BACK FROM CURB
PIPE BEDDING AND
CITYOF TI1FAR� _ BACKFILL_ DETAILS_
OREGONGA
by i_1PPR VED by L)V-A IN 5Y
G A IZ E5
t : -n1.E: t Art r)P-AW I N G Nc!
NT5 8/30/- 5-Z
IF
TRAFFIC CONTROL
GENERAL REQUIREMENTS
1 . The City' s standard specification for traffic ccnLrol is
"Manual on Uniform Traffic Control Devices for `'treets and
Higl,ways", U . S . Department of Transportat-ton, F'.,;I.A. , 1988 Ed.
2 . Traffic ccntroi shall be provided for, as illustrated, at all
time during work prosecution . No work shall be permitted
during the hours of darkness, nor between darkness to 8 : 30
a .m. , nor 4 : 30 p.m. to da_kness .
3 . Traffic control devices, flagpersons (etc . ) shall be in place
prior to initiation of construction work and shall, at all
times, be effectively maintained.
4 . The roadway shall not be closed to through traffic . The
contractor shall notify emergency services (fire, police,
et.c . ) , School District, and Tri--Met 72 hours (minimum) prior
to initiation of construction work. Advance warning of
imminent traffic disruption shall be provided to the general
motoring public by placement of an advance nctifi.cation sign
at each end of the construction area 72 hours (minimum) before
initiation of construction work .
5 . The City Inspector shall be notified 24 hours prior to
initiation of work (# 639-4171) .
6 . The work. area shall be maintained it a clean condition, free
from obstructions and hazards . Effective erosion ccntrol
measures shall be provided for .
7 . A temporary hard-surface patch shall be placed on all trenches
within the roadway at the end of each days work .
8 . Minimum travel-lane width shall be twelve (121 ) feet;
pedestrian -ravel shall also be provided for .
9 . The 'Ci.ty reserves the right to restrict construction
a-tivities during holidays and periods of high traffic levels .
The City reserves the right to add to or modify these
requirements as may be necessary to endeavor to more
effectively control traffic and to assura public safety; such
action shall not relieve the contractor of responsibility .
d�/enydac\masters` �gr.ms[
ROAD CONSTRUCT" T C
MEAD 1 I GENERAL NOTES
ML.
1. TRAFFIC SIGNS 10 BE 48" X 48"
CNE I_MJE
BLACK ON ORANGE.
`>
kUA) AHEAD
W20-4
2. NO ROAD CLOSURES DURING THE
µ+ FOLLDWING TIME PERIODS:
7: 30 — 8: 30 A.M.
Fl..A.GER AHEAD
W"G-7A J 4: 30 — 5: 30 P.M.
WIN, 3. THE CITY'S STANDARD SPECIFICATION
FOR TRAFFIC CONTROL IS "MANUAL
FLAccEH I ON UNIFORM TRAFFIC CONTROL
,o� ( DEVICES FOR STREETS AND HIGHWAYS",
U.S. DEPT. OF TRANSPORTATION.
"'N ■ �-4• F.H.A., 1988 EDITION
■ N
-- I°""— 4. ACTUAL SIGN PLACEMENT TO BE
I= Lra P ADJJSTED IN FIELD. DO NOT REDUCE
o BELOW MINIMUMS WITHOUT CITY
° APPROVAL.
MN
r 5. THE CITY RESERVES THE R'GHT TO ADD TO
I FLAGGi j�- OR '�ODIFY 1*R,,,FFIC CONTROL REQUIREMENTS
AS MAY BE NECESSARY TO EFFECTIVE!_Y
CONTROL TRAFFIC AND TO ASSURE PUBLIC
WIN,1SAFETY.
H,
FLA00ER AHEAD
W70-7A
LEGEPlD—
NIL
O ONE LANE V TRAFFIC SIGN
ROD AHEAD
W70-4
P CONSTRUCTION ZONE
100'
NN
to TRAFFIC CONES (J11
ROA1 APPROPRIATE DELINEATION
AHEAD HEA Ca15TR1CT1D/1 DEVICE.
A
TRAFFIC CONTROL
TYPICAL. DETAIL
DESIGN BY APPRCVEO BY I DRAWN BY
CAB
CITY OR TI G A R D SCALE DATEn DRAWING N0.
OREGON � N.T.S. 4-5 92
r" OF 1IGAI2D .'
EXPErIDI'ILJFiE E '1` j.
"Ms form i s �, uul ti-use farm. Apnropr-'at-at. recce ipts mus be attacher', Doca�rntation
i mpOrtant for all PUTPosc-s. Staple doo nentation to faro.
VEMM NO.: DATE:
PAYABLE T0: DK V , Z� M
- --
t 12T10 —_ * App--oved request Wednesday
10:00 AM to A/P for checks by
Friday.
b9l'AM IANEDUS EXPENDI'I1MM- : - -- -- --^ �
Date Description, Irw0ioe Vo., etc. No. Amount
7r �
2-2C
t �
TOML
Mileage $0.255
APPRC)RUATION BFIANCE: ___-- AS OF: --__ SIGMURE: _
(Up to $25.00) Section ManagEx .__ — Pu rd-J. Agent -- -- - —
($25.01-2,500.00) Division Manager —
-.($2,500.01-7,500.0o) Dept-. Head -- ---
($7,500.01--15,000.00) City Adtnvustrator
($15100r)-01- ?1 kcal Contract peview Eoard "— - -- —
�.(1501F — ----
„-.-...._. ._.«_•----•+•...-.--.-.+..-.-...-.�,.,,,�.M.�..,►w,.�.�w.,,�.,.,'.'a^"T�"t'�R'-"�wC..s'." ._—.�,.�.--......,.. -4..+.-..-n.-.�„r-T^,y,...._A,+"►p'f��..p-.�.�_ "K'rr-•aCT•�"'RM�-Iw+^y/?.'w
APPLICATION - STREET IMPROV”-HENT/EXCAVATION COPY TO:
OR 01 NAI'-E WO. 74-14 (WHITE)-FILE
(INSTRUCTIONS ON SEPARATE SHEET) (FELLOW)_INSP.
(PINK)- TFIER AGENCYi71c�,
(BLUE)-APPLICANT
APPROVED ]Sil
NOT APt-ROVLO (I I•Y i)1, I IGARU, OREON APPLICATION NO.:
PENDING FEE. PMT, 0 CITY Y I1AI,I, FEC AMT.: : 8.W
-E/
a
PENDING SECURITY RECEIO,:_ ELLm 4S'
PUBLIC WORKS DEPAR)"MFNT By DnTE,L L��Z
PENDING AGENCY "O N." U Appli(dlion and Progress Record 1 _ _ — — — — — — — —
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EY,CAVATION MAI ASE EQUIREpaND *.__-- ---
PENDING VARIANCEANNUAL
r +
1�
EXPIRATION DATE:
PERMIT NO.: 9
DATEISSUED: ' 1(,!
_. , 1 1 Z_ BY: ••c�c-'-'
-- - — --* -
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL A BU_ fI UI - SAN. EWER SER_VlCE _
LATEItA1. & LATERAL TIE AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT ---FOUR, D CCNMTRUCI'ION _ P.J. 130: 157.7 BEAV1 RTC•)N_�� 97075
ADDRESS -
CONTRACTOR (SAME) CITY _ PHONE
NAM Ab
PLANS BY PER CI NAME
STANDAIMDq AND SPECIFICATIONS _ clTv vHaNE
NAME
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): E 200•CYJ
DOLLARS
(2) EXC:,VATION DATA: �� FUR OFFICE US cMIN.
0.04 X 6_ 20 5.00 _ :_— 8.00
STREET DESCRIPTION
PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED --
TYPE LENGTH WIDTH DEPTH ITEM AI QUANTITY ITEM DATE REMARKS/rl•PE BY
STREETKNOLL [)fZIVF (SEE ,,TAC T P N D
INSP C-
R TION
E _
—_ Q
ESTIMATED STREET nPENING DATE:—_- U
�— f E
ESTIMATED STREET CLOSING DATE: -- f / S
T �-
- --_ F
(3) SECURITY NO. SECURITY AMT: � 200.00 STREET
SURETY CO.: --- _CLOSED
CERTIFIEp CHECK _----- - -- FINAL --
CASH ;7 EOND� INSPEC.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSI':AL ^—s—
FEATURES; EXCAVATION LOCATION AND EXTENT. SPECIAL PROVISIONS/CONDITIONS:
'__ Nptifv ir>,ar�ector Letha h
I (639-4171) 24 hrr.. before startinu
X11 ut�r)r shaI
I I
44v el���darcle & specifications.
Dae ( `� - ( l_ �-" Tri.- - . i e_-
--------------------
- ♦ � _ � nL7tifirr�E-i lllp� g � @Ei�
�. W. KNOLL DRIVE Traffic control must be provided
_ or_ y E We- can rac E or. •
yyy
k�' I vi __�- 1 The roa way �a :L not be c ,9ed
c
I Work area N .n_
I SITE: 12387 S.W. I I I 1,
Knoll Drive �* �►,., n•,rl of aan_►+cciay—___�.
Goncliltiol� of MLP 9_2-(?()J•7 dpply.NOTE: THE CITY OF TIGIIRE) DOES NOT, HEREBY, GRANT PERMISSION TO AR
RIGHT OF WAY JURIcDICTION IS THAT OF WASHINGTON COUNTY OR THE ^,TATE OF OR GONNDUCT WORK WHERE.
THE APPLICANT AGREES 1 J DEPOSIT THE REQUIRED SECURITIES, TO COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION 4PLCIF ICATIONS PERTINENT TO '^ONDUCT OF THE WORK, AND TO SAVE HARP14LESS THE CITY AND
EMPLOYEES AGAINST AN% INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS
� 1
API-11 (CANTS SIGNATURE �.�,, `�'�'•� -�' �A 1 '�.
DATE- / ) ! /
4i
CITY OF T I GARD - RECEIPT OF PAYMENT RECEIPT NO. :922-234571
CHECK (AMOUNT 1996. 8QI
NAME : FOUR D CONSTRUCTION CASH AMOUNT 0. 00
ADDRESS . PO PDX 1577 PAYMENT DATE-. 12/10/9.
BEAVE PTON, OR SUBDIVISION
97075-
PURP'.JEE OF PAYMENT AMOUNT PAID PURPOSE_ OF PAYMENT AMOUNT PAID
F'UE3LTC IMPROV 528 -92 40. 00 CUSTOMER DE 1000. 017,
PUBLIC IMPROV 529-92 8. 00 CUSTOMER DEPO 200. 00
PUBLIC IMPROV 5:30-92 28. 80 CUSTOMER DE:PO 720. 00
STREET OF'ErNING PE=RMIT/528-92', 529-92, 530-92
TOTAL. AMOUNT PAIL) - - -> 1996. 80
)ar�„w,• .•+.,.lu..n,w...r. w•,-."!.N,<rn.Nw•,,.•...a,.>•.M>.N,)y1AS,,prp...•.. . ',rr i'.i.i5, •<)•)'MN11NYf{)lNllNSOMSwvaalN!NNM)11•+)` •+ r"lnwlavihAlUlMNvu•wA4MMM1lVAIM)ONOSN.+I. MMt)HPNHY)M)nM
FOUR D. CONSTRUCTION CO. 1�5IO
eAwK N° 3114
PO 13OX 1577 641-0935 EAVERTON BRANCH
BOX 400, BEAVERTON• OR 870'70
BEAVERTON, OR 97075 UNITED STATES NATIONAL SANK OF OREGON
Z OSI
1230
PAY C.'� �y ar- A� o -' 199 �• 8c)
TO THE
ORDER OF DATE AMOUNT
l //V X i4/J D �O
100031,13t,11" is 1 2 3000 2 201: OSS 0 3 1, 2 1.6sill
CITY OF TIGARD
STREET OPENING PERMIT
Z � APPLICATION
! DATE
• APPLICANT'S NAME
ADDRESS
=F3UF- roPj ZIF'
PHONE
• CONTRACTOR'S NAME
ADDRESS
ZIP
PHONE
• PLANS BY
ADDRESS
ZIP
PHONE
• DESCRIPTION OF WORK PROPOSED TO BE DONE:
-- Cinyz:YAc_ ,t.,,9,k' 4--:-Ar
• ESTIMATED VALUE OF WORK (within public right-of-way) :
• WORK LOCATION/S'TE ADDRESS: ,Z-5 e 7Dar
• IS THIS WORK RE'ATED TO A LAND-USE ACTION? IF SO SPECIFY (MLP, SDR. ETC.) NO.
• IS THIS RELATED TO A BUILDING PERMIT? IF SO, SPFCIFY BLDG. PERMIT) NO.
d✓wv•nn (OVER)