12260 SW DUCHILLY COURT FILE NO.
OUCHILLY C^1. - 122EO STR. OPN. PERMIT
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APPLICATION - STREET IMPH( MENT/EXCAVATION COPY TO:
UkDINAIvrE NO, 74-14 ❑ (WHITE)-FILE
(BLUE) -INSP.
(INSTR',CTIONS ON SEPARATE SHEET) IYELLOW).OTHER AGENCY
(' IPINK)-APPLICANT
APPROVED ❑ APPLICATION NO.: 1_74
NOT APPROVED p CITY O1 TIGARD, OREGON FEE AMT.: S__A4 0 0 _-
PENDING FEE.PMT. ❑ CITY HALL FIECEIPT NO.:
PENDINGSECURITY ❑ PUSLICWORK COEPARTMENT BY �LT' DATE__ I__L
PENDING AGENCY "OK" ❑ Application and Progrrss Record _ � r � - - -
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION MAINTENANCE IDoND
PE'vPNNUALOING VARIANCE ❑ EXPIRA' N DATE: /
PERMIT NO.. DAlE ISSUED -��. _I.r BY:
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND IN;:MALI.
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT ��c�,y 6�4
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CIT PHONE
CUNTKACTOR __ IP/4dfr
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NAME AODRFSS -.�_--'.`__CITN p'C`QG--
Pl_ANS BY -_ _ _// /•
A D 4 g E SS C(�-- ••
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ -_.�/,
"—' DOLLARS
(2) EXCAVATION DATA: OR or ICE USE oMin:-
-- - OiQ$X S_— - $
STREET DESCRIPTION __ PROGRESS & INSPECTIONSTATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTAL LED "-
TYPE LENGTH WIDTH DEPTH ITEM & QUA VTI1 Y ITEM DATE REMARKS/TYPE BY
-� STREET "
PRED
INSP -'
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F_'
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ESTIMATED STREET OPENING DATE: / / r----� S
ESTIMATED STREET CLOSING DATE:- / / T --"'-"'- -- --'------
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(3) SECURITY NO. SECURITY AMT.: $ ��-�� --'TRF-ET _.
C! OSr_D
SURETY CO.: _
� FINALCERTIFIED CH!_CK Cl __CqS-H �BCNf, INSPEG.
_ _ _
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL "PECI.AL PROVISIONS/CONDITIONS: �-
FEATURES: EXCAVATION LOCATION AND EXTENT.
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NOTE. THF. CITY O' TIGARD DOES NOT, HERESY, GRANT PC12MI�SIrIN TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT-Or-WAY JUR1:DICTION IS ':HAT OF WASHINGTON COUNTY 0,7 THE STATE OF OREGON.
THE APPLICA.aT AGREES TO DEPOSIT THE REQIJIRED 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 ACTIJNS.
APPLICANTS SIGNATURE _� ' rL.,e4r� `jATEL�•.L-