9915 SW RIVERWOOD LANE _ FILE NO.
Rivecwood Ln. - 9915 Stc. Opn. Permit
` G11 OF TIS'
AIRF
EXPENDITURE REIMBURSEMEN- REQUEST
1
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This form is a multi-use form. Where appropriarr receipts must be attached.
Documentation is import-rpt for all purposes. Staple documentation to form.
VENDOR NO: DATE:
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PAYABLE T0: jC%rYl:l s f c�rri�s ��U Requested by. `
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MISCELLANEOUS (parking, books, subscriptions, dues, memberships, etc.) :
Date Descri tion Account No. Amount
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GENERAL MEAL EXPENSF.
*Date Description Amount
Account Number to be charged: � Total
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MILEAGE:
Date Description: (Includn end/start readings and total miles) Amount
Account Number: ._._. Total miles x$.21_
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APPROPRIATION BALANCE: AS OF: Signature
APPROVALS (if $25.00 or under may be reimbursed through petty cash) :
(up to $500.00)Section Manager _ Purch. Agent
($500.01-$5,000.00)Dept. Heau/Furch. Agent
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APPLICATION — STREE f IMP EMENT/EXCAVATION COPY TO:
ORDI '14CE NO, 74-14 - (w�IITE)-FILE
(VCLLOW)-INSP.
I.INSTRUCTIONS OU SEPARATE SHEET) OTHER AGENCY
)Z•APPLICANT
APPROVED AFPLACATION NO.: .3ZA- r
NOT APPROVED CI'I'N' OF TIGARD, OREGON FEE AMT.: $
PENDING FEE. PMT. [] GII'Y HALL RffcE1P _ —7zZ 3
PENDING SECURITY 0 PUBLIC WORKS DEPARTMENT BY_' DATE /
PENDING AGENCY "OK" ❑ Application and Progress Record
MAINTENANCE EYOI*D�ftV
PENDING INFORMATION I:1 FOR STREET IMPROVEMENT/EXCAVATION AS REOUI"Eu
ANNUAL
PENDING VARIANCE ❑ - — _� _ EXPIRATION DATE: go—44r__?F 7
PERMIT NO Z�g—c �_ DATE ISSUED: � ! 1. �4... . 9Y:
(1) r,r::f'LICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL _,5 ,;,___
.......__._-_. _.— AS DESCRIBED HERLiN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT
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r NAME A13ORL85 Q �.�_.. CI?'Y PHONE
CONTRAC fOR _A WY 1 � .-- C�— _ PHONE
NA e A oREss
PLANS BY
• ' AME___.._.._-____�.....__ ADO R'E S4 —__� CITY PHONE ._._
ESTIMATED IMPROVEMENT TOTAL VALUATION ! COST): f ��-v ,
DOLLARS
(2) EXCAVATION DATA: _ roR oPFICE usE cw !G c'MiN
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM OATE REMARK%/TYPE. BY
TYPE LENGTH WIDTH DEPTH ITEM A QUANTITY
STREET
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PEN D
E,1PI ON
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ESTIMATED STREET OPENING DATE:. „L_ / S
ESTIMATED STREET CLOSING DATE: � 1 � �— E:
(3' SECURITY NO STREET
_. . SECURITY AMT.: S � . CLOSED
SURETY CO.: -- -- - ------ FINAL
0�1�IO CHECK CAS" s1oND INSPEC. I1- �!--
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS: '
FEATUJZL'S; EXCAVATION LOCATION AND EXTENT. i!w //S &.63Y4/7/
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(5) NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERF.
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
CONSTRUCTIIoN 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.
APPLICANTS SIGNATURE tda .tat �-�,Y�wTa�l�_ DATE
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NAME:
DATE:
—�Ku Ki
—0- LOP 0Refundable Performance flond
—
.19--43600 Public Sewer P
�,ce
_
Lql:43600
Public S-1-0---T_Plan Check/In n F-e
Street
- —.—— - Dqdicati
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- c
Improvement
O—L36QOL— ��
Street
Q 41§00
Street Traffic Mar
-
11-44200 ---
Street
19-417J0Sic,, X22
THOMAS 0. TOMjkSELLO 96.-1029/3232
OC)L- 4267959
ogis sw RIVERWOOD t4 614
TIGAR0. OR 97224 ........
of
Payer
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Foxi, 323 , Cl
L ?0 q o .03000
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TOTAL
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CITYOF TIGARD No. 3 283
13125 S.W. HALL JLVD.
P.O. BOX 23397 Date -
TIGARD,OR 97223
Name
Address
Lot BlocklMap Subdivis?onlAddress
Per=# dg. Plumb �^ Cash Ch
Sewer Other Other y
Acct. No. _ Description Amount
10.432 Building Permit Fees
10431-600 Plumbing Permit Fees
10431-601 Mechanical Permit Fees
10-230-501 State Bid . *Tax
10-433 Plans Check Fee _
30.43 Sewer Connection
30-444 Sewer ine ectloo _-
51.44j1 Street Syst. Dev. Charge
52-449-810 Parks I Syst. Dev. Charge
52-449-_620 Parks 11 Syst. Dev. Charge
31•;;0 Storm Drainage Syct. Dov. Charge
10.430 Business Tax
10-434 _ Alarm Permit ^�
10-227 Bail - —
10.455- Fines- TrafficlMlsdlParking
10.230- CPTA TrafficlMisdlVic. Asst.
10-456 Indigent Defense
30-122.401 Sewer Service/USA
30122-402 Sewer Service/City 30%
30-1275— Sewer SevicelCity Malnt.
125 Unmatched _ _
1.124 Storm Drainage
0 Bancroif Prli;Tymt. `—� _
4 •4T1 Bancro tt Fnt. Pyit.
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ACCOUNTING
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