12700 SW 72ND AVENUE-2 FILE NO.
72ND AVE. - 12700 STR. OPN. FERMI:
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APPLICATION - STREET IMPRC 'MENT/EXCAVATION COPY TO:
❑ (WHITE)-FILE
ORDINANCE NO. 74-14 ❑ (BLUE)-INSP.
❑ (YELLOW)-OTHER AGENCY
(INSTRUCTIONS ON SEPARATE SHEET) ❑ (PINK) APPLICANT
APPROVED )01
FEE AMT.: E APPLICATION NO.: _ 7/
NOT APPROVED
CITY OF TIGARD, OREGON ---- – -�
PENDING FEE. PMT. ❑ CITY HALL. RECEIPT NO.:
PENDING SECURITY ❑ PUBLIC WORKSCJEPARTMENT BY DATE
Z i2d/7�
PENDING AGENCY ''OK" ❑ Application and Progress Record SB 32(033
MAINTENANCE BON
FOR STREET IMPROVEMENT/EXCAVATION It
PENDING INFORMATION El FOR REOUIRFU
ANNUAL ...
PENDING VARIANCE nn n❑ / EXPIRATION DATE:
PERMIT NO.: G / 7(/ DATE ISSUED: ��� _ — , BY: .Zlh' _ ET1 EL
(1 ) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL ._ _SE77V4 2 —
_. _ AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT it,/OiE'I��S Aom,6/.4G __ 1;7120 .S.ICS ,SN1iW �l�&.cy w0 -.554
�+I NAME _ ADDRESS CITY PHONE
CONTRACTOR _____ __ �_
NAME ADDRESS �CITY PHONE
PLANS BY __ —_ _ ____
NAME ADDRESS CITY PHONE
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ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $
OLLARS
(2) EXCAVATION DATA: LSTREET
FFICE USEa � -L)MI
STREET __ DESCRIPTION OGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM S QUANTIIG ED
`dSPEC-
IION
- - -' E
Q
ESTIMATED STREET OPENING DATE: S _
ESTIMATED STREET CLOSING DATE: .2 7 T
b ED
(3) SECURITY Nom3a33 SECURITY AMT: s—/ °_G STREET
CLOSE
SUREIY CO.:
CERTIFIED CHECK ❑ CASH ❑ BOND INSPrc..
(4) PLOT PLAN: INDICATE SITE PERTINENT' HYSICAL SPECIAL PROVISIONS/CONDITIONS:
FEATURES; EXCAVATION LOCATION IND EXTENT. _e Ll_oe4 rnL/�r�
--
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(5) NOTE. THE CITY OF TIG-7
ARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK INHERE
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 71" THE WORK, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
1 / l
APPLICANTS SIGNATURE: ,�.� DATE
CITY OF TIGARD--12420 S.W.MAIN—TIGAkD,OREGON 97223
RECEIPT
ti
DATE:
AMOUNT: $
DCLLARS
NAME- t CASH:
ADDRESS:_ /242�) CHECK
0 OF
FOR: 0 PERMITS SURCHARGE AMOUNT
SEWER BILLINGS 40-364
BUSINESS LICENSE 05-331
PLUMBING PERMIT 05-W)2
MECHANICAL PERMIT 05-332
BUILDING PERMIT 05-333
SEWER CONNECTION 40-363
SEWER INSPECTION 40-365
SYSTEM DEV.CHARGE 25-366
PARK DEV. CHARGE #1 30-367
PARK DEV,CHARGE *2 30-368
ZONING ADJUSTMENTS 05-362
TOTALS
RECEIVED BY:
PERMIT NUM§dRS ALE,4001111):
11 Numbw Amount Number Amount Number Amount
SL__
RECEIPT 0
21.12