3905 SW 141ST AVENUE 3905 S`YY 141ST, BEAVERTON OR
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APPLICATION - STREET IMPROVEMENVEXCAVATION COPY TO:
�� (WHITE)-FILE
ORDINANCE NO. 74-14 (YELLOW)-INSP.
) AGENCY
(INSTRUCTIONS ON SEPARATE SHEET) (BLUE)APPL CANT
II APaROVEG `P4 APPLICATION NO.: 344
(:I I'1. OF TIGARD, OREGON °
. NOT APPROVED [] FEC AMT.: 5 .. 404 00
_
PENDING FEE, PMT. [j CITY HALL. RECEIPT NO. J t
PENDING SECURITY [I Pi IC WORKS DEPA R TMEN T BY_----- DATE
- - - - - - - - - -
PENDING AGENCY 'OK'' ❑ Applilation and Progress Record
MAINTENANCE BOND M
PENDING INFORMATION ElFOR STREET IMPROVEMENT/EXCAVAI ION As saFauikEu
ANNUAL "r'1-Io 'l71�.1C
PENDING VARIANCE. I EXPIRATION DATE. T -
PERMIT NO.: DATE; ISSUED: --__-.�L_.---�-- -- BY: ._---.-__- -
sr.:aa..r_—i^-e�-�—__— ��--=--
(1) APPLICATION IS HEREBY MADE TO EXCAVATE I"OR AND INSTALI,. `'��" cxYaart3y� t"1i.1 l i
s•:L�. :;. +.>_ .i...jGj.s;: +�:1�•3 __ AS DESCRIBED HEREIN, IN IFJLL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT Lojr--Clark I.1110 Cu. 4 i4l
NAME: _----ADDRESS _ .._ CITV HONE
CONTRACTOk _—.-_.- �-
NAME - AooREss --� ___ _-- -.--- - PHaNm --
PLANS BY- !2oaL4:•tt.i-. - lnc.ip Inc._- I`-riell Rd. Eli:l.lra_borc: 1� 97.124 64�j.-33YA
— NAME ADf)RF..SS CITE— �Hp�
ESTIMATED IMPROVEMENT TOTAL. VALUATION ( COST): $ --
DOLLARS
FOR OFFICE USF..: 104.00 CMIN.
(2) E=XCAVATION DATA: 0.04 X n_ — = s _
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM & QUANTITY
—�- — --- STREET �-
----- IPENEsU — -- _
- —� NSPEC-
.',J, 7,', R TION
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ESTIMATED STREI.:T OFENING DATE: S
ESTIMATED STREET CLOSING DATE: .-�-�
STREET
(3) SECURITY NO. . ._- SECURITY AMT. S CLOSED
SURETY CO.: ___2`/ -',-' __'r _ FINAL
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CERTIFIflD CHECK CASH u EfOVD C�'. INSPE:C.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS/ CONDITIONS:
FEATURES, EXC:C VATION LOCATION ANI) EXTENT. •'IC. c10"�, SL's ( --1 i.1),
1.'g1_x'Ctor, :"'l tirs. r to
I I I � 1 c;Calnlrw,r)rF311,ent.
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S.W. 74Lh Avenue -
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(5) NOTE THE CITY OF TIGARD DOES NOT. HEREBY, GRANT PERMI!ISION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT OF-WAY JURISDICTION IS THAT OF WACHINGTOfi COUNT't OR THE STATE OF OREGON,
THE APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURIIIES, TO COMPLY W174 ALL PrRTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF TF'E WORK, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS '%CTIONS.
APPLICANTS SIGNATURE DATE _ _