15200 SW 72ND AVENUE FILE NO. 152--5:L
72ND AVE. 15200 STR. OPN. PERMIT
APPLICATION - STREET IMPRI' =.MENT/EXCAVATION COPY TO:
)-FILE
ORDINA,.oCE NO. 74-JA E] fOLUE)eLUE)-(NSP,
INSTRUCTIONS OSC] (YELLOW).OTHER AGENCY
( ON SHEET) C] (PINK) APPLICANT"
APPROVED ❑ APPLICATION NO.: 17/-
NOT APPROVED ❑ GI n' OI' TIGARD, OREGON FEE AMT.: _ I I
PENDING FEE. PMT. ❑ CITY HALL RECEIPT NO.: 173 r+
PENDING SECURITY ❑ PUB11C WORKS DEPARTMENT BY r_ DATE.
PENDING AGENCY "OK" ❑ Application and Progress Record MAINTENANCE BOND * AoOA
PENDING INFORMATION U FOR STREET IMPROVEMENT/EXCAVATION AS REDUI RED o
ANNUAL D A/—C3EXPIRATION DATE: 1�_Y-_
PERMIT NO.: /SA" It Z DATE ISSUED: L�1 Z— EiY:
(1) /APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INST,%LL _J`rny r# � �✓
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WI H CITY REQUIREMENTS.
APPLICANTa <� �/IS / / GrL� ✓_ `I_..-----
NAME ADDRESS
ADDRESS CI V PHONE
CONTRACTOR__ PHONE
PLANS BY--- NAME ADORVSS _ cl't�i PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ ►L __
DOLLARS
(2) EXCAVATION DATA: - - = Fo OFFICE USle le-t S `___ DMIN.
0.34.x $ - I �; �>�.d•
STREET DESCRIPTION _ PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTAL.L.EI) ITE14 DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM ti QUAN'T'ITY _
STREET
_ P
I TION
E
Q
_ U
E
ESTIMATED STREET OPENING DATE: �__..—� S
ESTIMATED STREET C L081NG DATE: / E
D -
','(REET
(3) SECURITY NO. SECURITY AMT.: $
SURETY CO.: _ _ _ FINAL
_CERTIFIED CHECK_0 _T CASN ❑ DONr._r INSPEC.
(A) PLOT PLAN: 'INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS:
FEATURES: EXCAVATION LOCATION AND EXTENT. 11
( �A 1'.� C,��►J Cd w��f e.J�ir�
CURB -
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1 I 1 I
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(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.
APPLICANTS SIGNATURE. DATE 9Z.-