11705 SW TIGARD STREET FILE NO. ,.`�� �"-)�
TIGARD DRIVE - 11705 STR. OPN. PERMIT
C1' 'OF I KARD
EXPENDITURE REIMBURSEMENT REQUEST lot
This form ib a multi-use form. Where appropriate receipts must be attached.
Documentation is important for all purposes. Stiple documentation to form.
VENDOR NO: I DATE: 11 - -Z _
PAYABLE TO: _ 1 1 C �1r ISV1 W► Requested by: —
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MISCELLANEOUS (parking, books, suhscriptions, dues, memberships, etc..) :
Date Description _ Account No. Amount
11 (6-Z7-r)00 3D0--
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GENERAL MEAL RXPENSE:
-Date D�_scri tion Ame wit
Account !lumber to be charged: Total
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MILEAGE:
Date Description: (Inclufie end/start readings a total miles) Amount
Account Number: _ Total _ miles x$.21 _
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APPROPRIATION BALANCE: AS OF: _ _-i Signature-
A"eROVALS (if $25.00 cr under may be reimbursed thr.3ugh petty cash) :
(up to $500.00)Section Manager - _ _ Purch. Agent
($500.01-$5,000.9o)Dept. Head/Purch. Agent _
.�7y
�ultrs.omlaela. Jouaty. Oro�on
Date_-___��� ` __Timew2.__�
WHILES YOU WERE OUT
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Phone
tELEPHONLD PLEASE CALL
RETURNED YOUR CALL WILL CALL AGAIN
WANTS TO SEE YOU RUSH -
Message_____
101,9
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ROUTING - REOUEST
Please I _
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❑I HANDLE F t►wokt . LIJ� _
LJ APPRUVE
and
❑ FORWARD
D RETURN w/RersU111-i
❑ KEEP OR DISCARD
❑ REVIEW WITH ME _
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RECE1VEn OC' 2
APPLICATION STREET IMPR �MENVEXCAVATION COPY TO:
(Y •
ORDIN,.iCE NO. 74-14 ( ELLOW)-IN
SP.
(INSTRUCTIONS ON SEPARATE SHEET) [I (PINK)-OTHER AGENCY
Xj= BLUE)-APPLICANT
c APPROVED APPLICATION NOJq
NOT APPROVED ,f CITY OF 'TIGARD, OREGON FEE AMT.: S
PENDING FEE. PMT. ❑ CITY HALL RECEIP�
PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT BY_ -- DATE
PEN'JING AGENCY "OK" E] Application and Progress Record MAINTENANCE BOLD is
PENDING INFORMATION C] FOR STREET IMPROVtMENT/EXCAVATION AS REQUIREU 1110
ANNUAL
PENDING VARIANCE ] EXPIRATION AT : _—
PERMIT NO.: Z919-B& DATE ISSUED. __ QQ
(1 ) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTAL[_
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WIT14eITY REQUIREMENTS.
APPLICANT _61 f~Y�-� .1 ��() �.LA), \ ► _G-- 1 ___� _� n
NAME ADDR[ff Y O PHONE
CONTRACTOR_ _ — 0-tL_
AM c ��DORF.3 CI V 1F �MONE —
PLANS B Y _ �:.� S�i�d._ a. E-1 be
NA
ADOTIESS city- �FIONe —
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S
DOLLARS
(2) EXCAVATION DATA: ^! FOR OFFICE UfE, 1,,+. �.r ('MIN.
0.04 X s --
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM A QUANTITY
STREET
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• t"I•�PEC-
_ R ?ION
- E —
0
ESTIMATED STREET OPENING DATE:..,--- F._� 1g
ESTIMATED STREET CLOSING DATE: T
—. E
D
_- OC7� E.. —4LOSET
(3J SECURITY NO. SECURITY AMT: S —_ _.
SURETY _ _ FINAL —
ObcHEC1c CASH ❑^ BOND , INSPEC.
(4) PLOT PLAN. INDICATE SITE PERTINENT PHYSICAL *� SPECIAL PROVISIONS , CONDFI IONS
FEATURES; EXCAVATION LOCATION AND EXTENT.
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(5) NOTE THE CITY OF TIGARD DOCS NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT-OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNT' OR PHE STATE OF OREGON.
THE APPLICANT AGREES 'r0 DEPOSIT THE RFOUIRED SECUR'TIES, X17 COMPLY W1 its ALL PERTINENT LAWS AND
CONSTROCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THIL WC;RK, AND TO SAVE HARMLESS THE CITY AND
EMPLOYECS AGAINST ANY INJURY OR DAMAGE W14ICH '4AY RESULT FROM APPLICANTS ACTIONS.
i/14� DATE
AiPLICANTSSIGNATOR[: .� ►� � / ���