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9166 SW NORTH DAKOTA STREET FILE NO. f3 STR. OPN. PERMIT_ NORTH DAKOTA STREET SW - 9166 GIT,. XTIGARD EXPENDITlIRE REIMBURSEMENT REQUEST I This form is a multi-use form. Where appropriate receipts must be attached. i Documentation is important for all purposes. Staple documentation to form. VENDOR NO: _ DATE: PAYAB E T0: Re ueuted b _ QiE:2v H.�- A c ho )& t q y .......... _= =ccaccaacacccv_acccc=c_ccr.G=ccccc ' MISCELLANEOUS (pr.rking, books, subscriptions, dues, memberships, etc. ) : Date ' Description Account No. Amount - Z200 o n+c� c c----s-a-----as-cae _ aaama=acor_cacc=e.cmr_-cecc----------erzr_ccmrc=c------m GEkRAL MEAL EXPENSE: I' •Date Description _ Amount Account Number to be cl,arged: _ Total cn :-c c:c ac ma cr_caysvc accasc.ca.cc_ _._�-ccc== --�_: ac._.cn:sacc�cacc_mcc=c.acac¢¢a-a MILEAGE: Date Description: (Include en.j/start readings and total miles•) Amount I Aceo.,nt Number:�Y -_ - Total-- miles x$.21 �----'------ --y------------a-r.¢rcvmncrcacvr rsasc=xcaaccc �_-m_ ---. ZCa=¢':E6C-CCC6¢CCSC.c�Li��CCsaC.0 APPROPRIATION BALANCE.: AS OF: Signature APPROVALS (if $25.00 or under only be reimbursed througl petty cash) (up to t500.00)Section Manager _ Puich. Agent ($500.01-$5,000.00)Dept. Head/Purch• Agent AV ,3Z Z. - 'F�CV SCQJ�SC. VAC- APPLICATION - STREET IMPRO' `RENT/EXCAVATION COPY TO: ORDINAL, ENO 74 14 (WRITE)-FILE 'LJ (YELLOW)-INSP. IINSTRUC:TIONS ON SEPARATE SHCET) ❑ (PINK)•OTHER AGENCY [j (BLUE)-APPLICANT APPROVED ( APPLICATION NO.: NOT APPROVED ❑ I Il' OP TIGARD, OREGON FEL AMT.: : 1,4, ca / ,�// PENDING FEE. PMT. ❑ CITY HALL RECEIPT NO.: C �D.1464 PENDING SECURITY p PUBLIC WORKS DEPARTMENT BY ---- DATE * [ /7/ / PENDING AGENCY ''OK ' p ;application and Progress Record MAINTENANCE BOND PENDING INFORMATION ❑ 1t FOR STREET IMPROVEMENT/EXCAVATION AS REQUIRED ANNUAL PENDING VARIANCE ❑ EXPIRATION DATE: -.---JL- PERMIT NO.: 3LZ ..4�. DATE ISSUED -_ - ��7i-ff BY: (I) APPLICATI' ' IS HEREBY MADE TO EXCAVATE FOR AND INSTALL A DESCRIBED HEREIN, IN FULL ACC RDANry WITH CITY REQUIREMENTS. APPLICANT I lYX<NA E -3cl ADDRESS CITY PHONE CONTRACTOR << 1 / NAS- ADDRESS - -' ----- CITYPHONE 39� PLANS BY _ __.----- NAME ADDRESS 1 ---ESTIMATED IMPROVEMENT IMPROVEMENT TOTAL VALUATION ( COST): $ l�© DOLLARS FOR OFFICDE USE: r:MIN 2.04 x S (2) EXCAVATION DATA: s C'.� - STREET DESCRIPTION PROGRESS & INSPECTION STATUS NAME SURFACE CUT CUT CUT MATERIAL INSTALLED TYPE LENGTH WIDTH DEPTH ITEM Illi QUANTITY ITEM DATE REMARKS/TYPE BY DI A C/t' Ce4 1� STREETD INSP R TION E �- Q U _ ESTIMATED STREET OPENING DATE: ES ESTIMATED STREET CLOSING DATE. - T --' E (3) SECURITYSTREET SECURITY AMT.: S_� _`� CLOSED SURETY CO.: __ FINAL — - CERTIRIED CHECK CASH _ SOND r. INSPEC. (4) PLOT PLAN: INDICATE ;ITE PERTINENT PHYSICAL- -�- SPECIAL PROVISIONS/CONDITIONS: FEATURES; ExCA V A TION LOCATION AND EXTENTS-- T 1 I ISI JC 1 1 t- �rf/% r" 1 ( '�vfl� I 1 1" 41 11 I I S I�� I I � i• 'C- • � �✓" f' at- 3 -¢ � (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 OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS, 7 APPLICANTS SIGNATUR `��'� 6�/> 117 DATE v' BEAVER STATE PROPERTIES 0214 2096 SUNRAY CIRCLE 293-8580 WEST LINN, OREGON 97068 //J 19 QO 24-22 131 a / 1230 T Pei O The Order The U.S. BANK 102ND 6.WASHINGTON BRANCH ^ P.O.BOX 16086 PORTLA N0.0M0721 a .ORB721B NITEO 9TATE9 NATiO NAI AA NOF OIIl60N 1: L230002901: L 3 L 00 5 X02 �' '�, 4 i