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APPLICATION - STREE C IMPROVEMEN UEXCAVATION COPY TO:
ORDINANCE NO '4-14 I3(WHITE)-FILE.
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(INSTRUCTIONS ON SEPARAI"E SHEET) PINK)-( 1EI+ AGENCY
Q�� (BLl1E)-N.PLICANT
1
APPROVED ® APPLICATION NO.: —346
NOT APPROVED ❑ (J'FY OF TIGARD, OREGON FLL AMT.: S-1,600.00 -
PENDING FEE. PMT. ❑ CI Il• HALL RECEIPT NO.:
PENDING SECURITY ❑ PUBLICVt'D,RKSDEPARTMENT r+v _r____-__. DATE----L
PENDING AGENCY "OK" ❑ Application and Progress kecord MAINTENANCE BON at
PENDING INFORMA'r1ON ❑ FOR STREET IMPROVEMENT/EXCAVATION �- RVQUIRED ----�-
ANNUAL U
PENDING VARIANCE ❑ � �I EXPIRATION DATE: `ane YeaF _
PERMIT NO ' _ DATE ISSUED. ; _ i _ BY:
n'iber Upt c Cable CroJss ngs
(1) APPLICATION IS HEREBY MADE TO EXCA�VpATEE FQ1RV AND INSTALL
NDINSTALL .._.�
1.dRiUflLr.Na`LS'iWElsloCBthW�aslRE523 t1E;ULLCCOF!,f�ANCE WITH CITY REQUIREMENTS.
APPLICANT Coates Vield '3ri►ic@, Inc. (Agent) Building 1fr8,prX.tland, OR 97218 253-1811
NAMK O �S CITYPHONE
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CONTRACTO� COnstruc ion 8862 Ste Cent4r Ct., Tigard, JXt 97223 (St.Helens office)Z
661r
ADDRESS CITY _ PHONE
PLANS BY DAvid Evans � Assc , Inc. 1142 <y L 1 ..A illespie Rd, Suite 30, u;ugene 97401 342--2411.
NAME ADDRESS CITY --vmON-E
ESTIMATED IMPROVEMENT ?OTAL VALUATION ( COST): $ _ 4010w•w _
_
DOLLARS•—
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(7_) EXCAVATION DATA: -Fon XFsy�'I — 1,600.00r,"' -
STREET _ _DESCRIPTION _ PROGRESS & INSPECTION STATUS _
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM & QUANTITY
North 13akot. _ STREET
OP
Ij N
lir*3 lan ,i,ok lace I c:'.,,ched I N
R *T ONE
"Ip► :k. plans EQ --
ESTIMATED STREET OPENING DATE E:–��_ � g
ESTIMATED STREET CLOSING DATE: _ _ E
(3) SECURIIY NO. • G-~ SECURITY AMT.: : 40``n'�•`x`. CTLOSED -
SURETY CO.: F_ c;� • .�• - '- •� r ,�_ - FINAL
cEaTIF1En r ti6c I
AS
❑ + •OND INSPEC, —_
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISICNS/CONDITIONS:
FEATURFS, EXCAVATION LOCATION AND EXTENT, 1. A 1 1 work shall conform to the
plans and to City Standardm &
9pecificat:ions. _
I ( I + I I 4ot.ifY City inape tr.x, Mr. Miko
CURB - mi113 (639-4171) 7ior t
initiating each Ate- einq.
(:7«� attactuK3pl.�Iirs) --�
1'rAfftc control i._-,,s & JrLac&
.c �• - - - - - - - - - - - ::Is, if necassary, shall be++
�I -- ------� __-._-- _ ;tiroyided duci.ny the courmo Of
( ( I I I
work rstla.11 _t,n
conaideced c-al,rr
Tete un A invritinq
(S) NOTE THE CITY OF TIGARD DOES, NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO C01YDUr'r WORK WHERE
RIGHT-OF-WAY JURISDICTION IS THAT OF WASHINGTON COU14TY OR THE STATE OF OREGO^I,
THE APPLICANT AGREES TO DEI'OSIT THE REQUIRED SECUFATIES, TO COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT' OF THE WORK, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINST ANV INJURY OR DAMAGE WHICH MAY RESULT FROM APP_ICANTS ACTION.
APPLICANTS SIGNATURE ` �^_.rt.� DATE