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FILE NO. JL2-q
72ND AVE. - 15785 STR. OPN. PERMIT
VENDOR
ADDRESS
CITY, STATE, ZIP C17YOF TIIFAPD
DATE � P.O. #
WASHINGTON COUNTY.OREGON
CHECK ONE: [;� .y i #i-avv-xecei ed Lhe_-.following.. Please make
i--� REQUISITION
payment. (Forward to Accounting.)
Received:
aDate Initials
I have ordered the following. Please issue OTHER INFORMATION:
a confirming purchase order. (Forward to
Administrative Secretary.)
I have researched the following. Please ,, ,
issue a Purchase Order. (Forward to greet �'.)oeni.ng P,,irmit
QAdministrative Secretary.)
I want to buy the following. Please research)
Return price information to this office. - ---
(Forward to Administrative Secretary.) -----
ACCOUNT # QUANTITY DESCRIPTION (Please explain thoroughly) UNIT PRICE TOTAL PRICE
� I
TOTAL, AMOUNT DUE ; -
DEPARThiENT HEAD APPROVAL t
FINANCE DIRECTOR APPROVAL:
( for 600 Accounts over $2,500, and all 700 accounts)
DISTRIBUTION: White - Pur. Coord. or Accounting
Yellow- Department Copy
APPLICATION -- STREET IMPRr 'MENT/EXCAVATION COPY TO:
%--fN(WHITE)-FILE
ORDIN....CE NO. 74-14 91(BLUE)-INSP.
V ELLOW) -OTHER AGENCY
(INSTRUCTIONS ON SEPARATE SHEET) )PINK) - APPLICANT
APPROVED APPLICATION NO,:
NOT APPROVED ElCITY OF TIGARD, OREGON FEE AMT.: f—._At—_.___�_
PENDING FEE. PMT. ❑ CITY HALL RECIE
PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT BY_ = DATE 3 / l01 'C�
PENDING AGENCY "OK" O ;Application and Progress Record
MAINTENANCE BONY
PENDING INFORMATION ❑ FOii STREET IMPROVEMENT/EXCAVATION AS REQUIRED --`--
ANNUAL
PENDING VARIANCE 1 1 ❑ EXPIRATION DATE:
PERMIT NO.: _�� � _ DATE ISSUED: — �ln/ �' BY: _ a �--
(1) APPLICATION: IS HEREBY MA - E TO EXCAVATE FOR AND INSTALL drivQKaY—akpr4acr and_culvert __ .
(-MO-iA& to_newlOcati_o__n__- AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
on same lot)
APPLICANT __Andre' Nadeau, 906A I ecan Court, Newberg, OR 9713'
538-6475
NAME ADDRESS CITU -- -- --" PHONE --
CONTRACTOR-Sa►►►e _____-`---------__ --
NAME ADDREff
PLANS BY _ _;3ja y I' an Service, 7666 SE 20th St, I ortland- JR _ 6578
NAME ADDREfS CITY --_ "� -PFfONE—
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ _ 200.0
—___. DOLLARS
(2) EXCAVATION DATA: _ FOR OFFICE Ufe: - -� tI MIN
0.02 X f—Z �� = f
SYREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE ^.EMARKS/TYPE HY
TYPE LENGTH WIDTH DEPTH ITEM A QUANTITY
72nd Ave, halt_AsL1 1 I 1211 ��a. CU1VP.rt 11TREET
and 15 yds. gral R T
veI0
E
Qu —
ES' MATED STREET OPENING DATE:____AJ_)rtl / I x_1950 Ea
ESTIMATED STREET CLOSING DATE: __AApril / 1 / 1980 g
_—_ :�-�--- -- ------ - D
STREET
( I) SECURITY NO. SECURITY AMT.: E�t ( �__� CLOSE
SURETY CO.: . FINAL -_-
CERTIFIED CHECK CASH U INEPEC.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS:
FEATURES: EXCAVATION LOCATION AND EXTENT.
See Attached copy of aite plan T I -
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(`I) 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
FMf`LOYEE-.i AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS
APPLICANTS SIGNATURE. DATE -/fjt'_ ^ /�
-
!'
Al .
,. op 1..
.!r
0.00
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CITY OF TIGARD—12420 S.W.MAIN—TIGARD,OREGON 97223
RECEIPT
�— ILS-�l0
DATE: � AMOUNT: $�--��` U c� — ♦t JOS
r, az v
1.0
NAMF: Ck -- CAS y
-- �--- 1
ADDRESS:
10
? M.U.: ..-•.
OF
FOR: ACCT. 0 PERMITS SURCHARGE ! AMOUNT R •-NN
SEWFR BILLINGS 40-364
BUSINESS LICENSE 05-331
PLUMBING PERMIT 05-332
MECHANICAL °ERMIT 05-332
BUILDING PERM T
05-: 3 _
SEWER CONNE—'TION 40-363
SEWER INSPECTION 40-365
SYSTEM DEV.CHARGE 25-366
PARK DEV. CHAIO-E #1 30-367
PARK DEV. CHARGE #2 30-368
ZONING;ADJUSTMENTS 05-362
j4C 4b "
TOTALS
RECEIVED BY:
PERMIT NUMBERS ASSIGNED: v
Number Amount Number Amount Number Amount
S ( RECEIPT / - - —
+ 5215
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