11959 SW PACIFIC HIGHWAY-1 FILE NO. 490-92
PACIFIC HIGHWAY, 11.959 STR OPN PERMIT
�. COPY TO:
APPLICATION - STREET IMPRO�MENT/EXCAVATION lii (WHITE)-FILE
OR UI NAA,E NO. 74-14 p (YELLOW)-INSP.
(PINK)-OTHER AGENCSIC�-
(INSTRUCTIONS ON SEPARATE SHEET! (BLUE)-APPLICANT
APPROVED Q APPLICATION NO.: S 5'
NOT APPROVE) ❑ (.11 Y OF TIGARD, OREGON FEL AMT.: :
CITY HALL RECEIPT NO.: y1--_ 3
PENDING FEE. PMT. 0 5I� qZ
PENDING SECURITY [1 PUBLIC WORKS DEPARTMENT BY-�_ DATE _ _ - - - -
PENDING AGENCY - OK" F3 'application and Progress Record MAINTENANCE BOND if --
t�---17 FOR STREET IMPROVEMENT/EXCAVATION AS REOUIREI) v�
PENDING INFORMATION J ANNUAL
EXPIRATION DATE:
PENDING VARIANCE
PERMIT NO -4aD-�nuDATE ISSUED: 5 -- �Z BY: —#�--- ---- -
CY
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND%AWMA- � =' 31de�a]lc`J� 'lJ
CaT
i)IW �kA:c7r1', t-V ca:ir>drau'1s to exiBL.C.B•AS DESCRIBED HEREIN, IN FULL ACCOr.OANCE WITH CITY REQUIREMENTS.
David Brad 1L*J 3aBasaLl In �. 3u~ <_'�, ;��11 xzxror (1: 97123 640-6123
APPLICANT __—__—___ ___ '— FHai+e
_ ___. _..- C I7 V
NAME ADbN[45
6xe -- --
CONTRACTOR --------- ADOREss`— J CITv ----FwoNE
AMC
N
PLANS BY-._...` C#Y SnabCdS & LCatla'15
NAME ADDRESS CITU -_ FHONE -
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ 1025•00 --
DOLLARS -- - --
_. _- FOR OFFI t U t: - _.MIN.
(2) EXCAVATION DATA: — on4 X s T�•� '— --
DESCRIPTION PROGRESS & INSPECTION STATUS—
STREET --
SURFACE CUT CUT CUT MATERIAL, INSTALLED ITEM DATE REMARKS/TYPE B
NAME TYPE LENGTH WIDTiEPTH ITEM & QUANTITY
STREET'
N
--- INSPE .
d,'t[l Avenue (:3L'E' atta 1X:1) E TION
Q
U —
E
ESTIMATED STREET OPENING DATE:--_---� -- S -- --
T
ESTIMATED STREET CLOSING DATE: - ) E
D
1025.1�U STREET
SECURITY AMT' E _ _ CLOSED _
(3) SECURITY NO. _.. - FINAL I.
SURETY CO.: ---- --- — - INSPEC. , •rc�e..
CERTIFIEV CHECK 11 CASH 13 BOND , -- _
- TJ - SPECIAL vROVISIONS / CONDITIONS.
(4) PLOT PLAN' INDICATE SITE PERTINENT PHYSICAL
FEATURES; EXCAVATION LOCATION AND EXTENT. 1 IbtiLy Citl Irepectoc Cac'1 \ht-AM,
I
SlZa fir's. befa� starLiJiy 4JOL�,C.
I '11r: ]19 yj3�] PaClf l.iv LJtf.
2.All =.'c silall IxTlfacTn to Citi Starczizta
1 i work acm & 4-Aifi,..ntdals; see attacry-xi.
1
,)'^ � X X X X x}C X }i X X}C X X X X X �� � I I� - - 3•�S ��a)•541-.5/1 a�Jlys (m: uti..lit,f lb.
URB I - - - 2+ I ifiCatiGni BtC.).
3n1 87th A Je ---.------ — r�1 I 4.f
is. 9 il.l ilm&at�_ly be t-mov d crtll
I I tilp-- work site.
•c,Al% —,I
—.I — — — — -- — — — — — I• _ _ �.P�rii�BtCL][l tcaffic O:ttXui -tuU Oe
'mvided far at 311 turns.
1
1 1 I
I Z
=
NOTE "HE CITY OF TIGAR'7 DUES NOT, HEREBY, G1?ANT rERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
(51
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 SPE:IFICATIONS PERTINENT TO CONDUCT OF THE WORK. AND TO SAVE HARMLESS THE CITY AN
EMPLOYEES AGAINST ANY INJU 4&RF 1SAMAGE WH4 C"lAAY RESULT TM APPLICANTS ACTIONS
r
.-__ DATE
APPLICANTS SIGNATURE — ---------
1
R/W
-5• MW.
CURB JOINT SEE NOTE 5
2
ROAD /' • - - - I
C2" OF 3/4"--0
COMPACTED SUBGRADE
SIDEWALK ADJACENT TO CURB
R/W
- 5 MIN 6• -
i
2
ROAD
_ Iii 3
III TSEE NOTE 5 1
2" OF 3/4"-0
COMPACTED SUBGRADE
SIDEWALK AWAY FROM CURB
NOTES
I. CONCRETE SHALL BE 3000 PSI AT 28 DAYS , 6 SACK MIX , SLUMP RANGE
OF I V2" TO 3"
2 PANELS 1'0 BE 5 FEET LONG
3. EXPANSION JOINTS 1"0 BE PLACED AT SIDES OF DRIVEWAY APPROACHES ,
UTILITY VAULTS WHEELCHAIR RAMPS, H AT SPACING NOT TO EXCEED 45 FT.
4. FOR SIDEWALKS ADJACENT TO THE CURB 9 POURED AT fHE SAME TIME AS THE
CURB, THE JOINT BETWEEN THEM SHALL BE A TROWELED JOINT WITH A MIN 1/2"RADIUS.
5. SIDEWALK SHALL HAVE A MINIMUM THICKNESS OF 6 INCHES IF MOUNTABLE
CURB IS USED OR IF SIDEWALK IS INTENDED AS PORTION OF DRIVEWAY .
OTHERWISE SIDEWALK SHALL. HAVE A MINIMUM THICKNESS OF 4 INCHES .
6. GRAIN BLACKOUTS IN CURBS SI-'ALL BE EXTENDED TO BACK OF SIDEWALK WITH 3"DIA. PLASTIC
PIPE AT 2 % SLOPE C14TRACTION JOINT TO BE PLACED OVER PIPE.
I
DEPARTMENT OF LAND USE
WA,3HINGTON COUNTY CONCRETE SIDEWALK
AND TRANSPORTATION
DATE CIVIL ENGINEER DRAWN APWA NO. WASK COUNTY NO.
NONE CS - 305
J
O�
6"x 6" 10 GA - -0" MAX. -0MINS RAW LINE
MESH DRIVEWAAYY
OPTIONAL
SIDEWALK
W LOCATION
ac
CURB J01NT
�- COf''RACTION JOINT
B EXPANSION JOINTS
SInEWALK EXPANSION JOINTS
A71
3.-0" T.- 6" MIN. 7' -6" MIN. 3` - 0'. FACE OF CURB
0" MAX. X- 0" Ml X.
Is PLAN iS'
1 - 1,2, EXPOSURE
USE EXISTING EXPANSION JOINT OR
SAWCUT AND PLACE COLD JOINT.
SEE OWG. NO. CS-306.
ELEVATI O fJ B-B
IW
`2
STREET
�. r
6"
10 GA. MESH ,"
,. OF 3/4" MINUS
1-1/7" ABOVE
BASE --- SECTION A--A
1. CONCRETE SHALL HAVE A MINIMUM BREAKING STRENGTH OF 3000 PSAL
AFTER 29 DAYS , 6 SACK MIX .
2. CURB JOINT SHALL BE A TROWELED JOINT WITH A MINIMUM 1/2" RADIUS
ALONG BACK OF CURB.
3 EXPANSION Jn!MIS SHALL BE 1/2* PREMOLDEO ASPHALT IMPREGNATED
MATERIAL OR EI)UAL, EXTENDING FROM SUBGRADE TO FINISHED GRADE.
4. SEE OWG. NO. CS-300 AND NO. CS-305.
AlftWASHINGTON COUNTY
WDEPARTMENT OF LAND USE COMMERCIAL DRIVEWAY
AND `TRANSPORTATION
DATE CIVIL ENCIPMER DRAWN APWA NO. WASH COUNTY NO,
Rvs 66* NONE DW--201
- if -
FAL,_ OF CURD DRAINAGE DLOCKOUT
WIDTH OF STREET 3" I.D. PLASTIC PIPE
WITH COUPLING
I" R -- 6" 1/2" R
,
ROAD I
11 '
MAX. iO
e
BASE COURSE •
v °o
9"
1• FOR DESIGN SPEEDS GREATER THAN 40 MPH THE EMERGENCY MOUNTABLE
CURB CS-300 SHALL BE USED.
2. CONCRETE TO HAVE A BREAKING STRENGTH OF 3000 PSl AFTER 28 DAYS.
EXPANSION JOINTS . 1
A, TO BE PROVIDED =
U AT EACH POINT OF TANGENCY OF THE CURB
2) AT EACH COLD JOINT .
3) AT EACH SIDE OF INLET STRUCTURES.
4) AT EACH END OF DRIVEWAYS .
9) AT LOCATIONS NECESSARY TO LIMIT SPACING TO 4! FEET
B. MATERIAL TO BE PRE - MOLDED, ASPHALT IMPREGNATED, NON—EXTRUDING,
WIT14 A THICKNESS OF 1/2 INCH.
3. CONTRACTION JOINTS .
A. SPACING TO BE NOT MORE THAN 13 FEET
D. THE DEPTH OF THE JOINT SHALL BE AT LEAST IV, INCHES .
4. BASE ROCK -2`-0 OR 3/4"-9 , 93% COMPACTION. BASE ROCK SHALL BE TO
SUBGRADE OF STREET STRUCTURE OR 4" IN DEPTH , WHICHEVER IS GREATER
S. DRAINAGE BLACKOUT • 3" DIA. PLASTIC PIPE .
A. I.D. PLASTIC PIPE WITH COUPLING.
B. DRAINAGE ACCESS THROUGH EXISTING CURBS SHALL BE CORE DRILLED OR CURB
SAW CUT VERTICALLY IB" EACH SIDE OF DRAIN 8 REPOURED TO FULL DEPTH OF CURB.
WASHINGTON COUNTY CURB NON MOUNTABLE
DEPARTMENT OF LAND USE FOR USE ON MEDIANS
AND TRANSPORTATION
DATE CIVIL ENGINEER DRAWN A.PWA NO. WASK COUNTY NO,
/-7/464 A - — _aL� 18 ( MOD.) CS - 3101
- 92
TRAFFIC CONTROL
GENERAL REO.UIREMENTS
1. Traffic control shall be provided for, as illustrated, at all
time during work prosecution. No work shall be permitted
during the hours of darkness, nor between darkness to 9:00
a.m. , nor between 4:00 p.m. to darkness.
2. Traffic control devices, flagpersons (etc. ) shall be jjjac
prior to initiation of construction vork and shall, at all
times, be effectively maintained.
3. The roadway shall pot be closed to through traffic. The
contractor shall notify emergency services (fire, policy,
etc. ) , School District and Tri-Met 72 hours (min.) prior_ to
initiation of construction work. Advance warning of imminent
traffic disruption shall be provided to the general motoring
public by placement of an advance notification sign at each
end of the construction area 72 hours (min. ) before initiation
of construction work.
4. The City I_ -,pector shall be notified 24 hours prior to
initiation of work (1 639-4171) .
5. The work area shall be maintained in a clean condition, free
from obstructions and hazards. Effective erosion control
measures shall be provided for.
6. A temporary hard-surface patch shall. be placed on all trenches
within the roadway at the end of each days work.
7. Minimum travel-lane width shall be twelve (1.21 ) feet;
pedestrian travel shall also be provided for.
8. The City reserves the right to restrict construction
activities during Holidays he ri thtp to periodsoff to hightraffic
rmodify levels.
The City reserves g
requirements as may be necessary to endeavor to more
effectively control traffic and to assure public safety; such
action shall not relieve the contractor of responsibility.
dj/n-tc9r.JN
ROAD CONS UCTM p
AHEMGENERAL NOTES
T
1w
MN.
1. TRAFFIC SIGNS TO BE 48" X 48"
BLACK ON ORANGE.
ONE+u,E O
NllAO At*-
` 2. NO ROAD CLOSURES DURING THE
100 I FOLLOWING TIME PERIODS:
�N.
7: 30 — 8: 30 A.M.
� „ AHEYLLp I
4: 30 — 5: 30 P.M.
W2&-7A
100.
MIN. 3. THE CITY'. STANDARD SPECIFICATION
FOR TRAFFIC CONTROL IS 'MANUAL
L— �I ON UNIFORM TRAFFIC CONTROL
c�.,ocER DEVICES FOR STREETS AND HIGHWAYS",
U.S. DEFT. OF TRANSPORTATION,
MN. ■ -� F.H.A., 1988 EDITION.
IN SIT
-- 4. ACTUAL SIGN PLACEMENT TO BE
! , ADJUSTED IN FIELD. DO NOT REDUCE
—{ 6tLOW MINIMUMS WITHOUT CITY
■■ I APPROVAL.
0 N
■ 5. THE CITY RESERVES THE RIGHT TO ADD TO
• OR MODIFY TRAFFIC CONTROL REQUIREMENTS
ICFUGGER
f AS MAY BE NECESSARY TO EFFECTIVELY
CONTROL TRAFFIC AND 'TO ASSURE PUBLIC
,I
MIN.. SAFETY.
W20--?A
LEGEND
+DU'
WIN
Q TRAFFIC SIGN
<> � ONE UNE
RW AhEAD
M20-4 ® CONSTRUCTION ZONE
100M
v T,'AFFIC CONES OR
APPROPRIATE DELINEATION
I - nnAo couTRucnoN DEVICE.
AHEAD
_ --�------ `---� ---- -��-'- TRAFFIC CONTROL
TYPICAL DETAIL
DESIGN BY APPROVED BY DR AWN BY
CAB
CITY OF TI G A R D SCALE — DATE --- DRAWING NO. V—
OREGON 11.T.S. 4--6-92 —J
.DEFINE:entrct-=case->eng defin..tion incorrect
ENGINEERING PERMIT
PERMIT #. . . . . . . : ENG92-0029 DATE ISSUED: 05/18/92 By:
PRIM. PERMIT #. : ENG92-0029
STTE ADDRESS. . . : 11959 SW PACIFIC HWY PARCEL: 1S135DD-02700
SJBDIVISION. . . . : HOFFARBER TRACTS NO.1 ZONING: C-G
BLOCK. . . . . . . . . . . LOT. . . . . . . . . . . . . : 1
---------------------------------------------------------------------------------
PERMIT TYPE. . : SOP IMPROVEMENTS QUANT RATE VALUE
AGREEMENT DATE: / / GRAD/EROS
ASSURANCE EXPIRATION--- STREET
PERFORMANCE: / / SAN SEW
MAINTENANCE: / / STM SEW
UTILITIES
ALL OTHER
TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
Remarks: STREET OPENING, TO REPAIR AN EXISTING DEFECTIVE CONCRETE SIDEWALK AI4D
INSTALL A CONCRETE D/W APPROACH AT SW 87th AVE. AND, ALSO, TO TIE EXISTING ROOF
RAIN DRAINS TO AN EXISTING STORM C.B. IN SW 87th AVE.
Permittee: ---------------- FEES -•-------------
DAVID EMAMI type amount by date recpt
1049 S.W. BASELINE RD. STE#420 OPEN $ 41.00 SRS 05/18/92 227398
HILLSBORO OR Ti123
Phone #: (503) 640-5123
Engineer:
ENGINEER NOT ON FILF
$ 41.00 TOTAL
Phone #:
------- REQUIRED INSPECTIONS -------
Permittee/Agent Signature: ---STORM SEWER-- -----STREET-----
__ _ M.H. & C.B. CRB LINE & GRADE
PIPE LN & GRD SUBGRADE
BCKFLL, & CMPCT BASE ROCK
AIR & TV TEST LEVEL COURSE
City of Tigard, Oregon WEARING COURSE
13125 S .W. Hall Bled. ---SAN. SEWER--- TRAFF & PED CUNT
P.O. Box 23397 M.H. & C.O. MONUMENTATION
Tigard, Oregon 97223 PIPE LN & GRD STREETLIGHTING
Phone #: 639--4171 BCKFLL & CMPCT WALK/APRON/RAMP
ASR & TV TEST
FOI< INSPECTION, CONTACT: ----GRADING•-----
Carl Vieweg #639-4171 (office) --REPR' S/ADJ,S-- CONTOURS
#790-2647 (mobile) DRAINAGE
-- --PATHWAYS---- EROSION CNTL.
CM OF TIGARD
D(PENDITURE RK�U
qbjz; form is a multi-use form. Appropriate receipts mist be attached. Dounwntation
important for all rxuTxk;es- Staple docxm�ontation to form.
VENDOR NO.: DATE: 19 C1-L
PAYABLE TO: RT-WESTED BY:
i 04 G&g 'Z 2 „Ae-
1 lo c,I-n 11-71 Z Approved request ue Wednesday
10:00 AM to A/P for checks by
Friday.
MISC�3�ANDJiJS E(PENDI'1TJ32E5:
Date Description, Invoice No., etc. Ar-xxrunt No. AnKxint
------ .E.FV�� pt- /�S.�St,�tlyt�,E� �__��_. .—gyp —ZZ(��L�— +�$ ��Z� ,�.ca
_K4
TOTAL C)z 5,
Mileage $0.255
APPROPR=ON BALANCE: AS OF: SIGNATURE-
(Up to $25.00) Section Manager. Purch. Agent
($25.01-2,500-00) Division Vorager
($2,500.01-7,500.00) Dept- Head
($7,500.01-15,000.00) Cit-Y Administrator
($15,000.01- ?) Local Contract Review rkxlrd
!1501F
-•----�•-.-,.�-.--•...�.q..�...,P,„,,,.,r..,_.,,.._rr^�-�^....-s..---+ter-;'�.-.�..,.-..,�..,.,,. -s+n.
APPLICATION - STREET IMPROVF- 'cNT/EXCAVATION COPY TO:
ORDINAN(-- NO. 74-14 10 (WHITE)-FILE
® (YELLOW) -INSP.
(INSTRUCTIONS ON SEPARATE SHEET) (PINK)-OTHER AGENCIA"J.
J (BLUE)-APPLICANT
APPROVED 13 APPLICATION NO.: S3 S�
NOT APPROVED U CI I Y OF TIGARD, OREGON FEE AMT.. S 4i-lJ)
PENDING FEE. PMT. ❑ CI Y liALI. HIECEIPT NO.: 7(9 D
PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT 13Y - -5eS
DATE _-r ` �
PENDING AGENCY "O!<" [-j \�,ivafinn and Progress - - -
{! 1{ress Recor.
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION MAI ASEEQ"REeoNo R i
PENDING VARIANCE ❑ AMNUAL
EXPIRATION DATE: -_
PERMIT NO f�-_qp- = _DA"fE ISSUED: _A�_j _�?-L_ , BY: --Ski
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTAIOL - aLr ext:;_
Il/W i�jLY]1; t7 clairLjLaLru to exist.t. `.AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
A PPL I C h N T DRVul FlMlyd ib., -lute 42U, HLLIAX Lro, CR 9'/12 6eD-6j Z I
AME ADDRESS CITU PHONE
CONTRACTOR __ `ave I
AME ADDRES CITY
PHONE
r L A N S B Y f7aC City 3tarlc aiS rxit ics�tta�;
NAME ADDRESS
CITY PHONE - �
ESTIMATED IN,PROVEMENT TOTAL VALUATION ( COST): $ 1 •W
DOLLARS
(2) EXCAVATION DATA: FOR OPFICiE,II$E MIN.
0.04 X S = E •� __
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED
TYPE LENGTH WIDTH DEPTH ITEM & QUANTITY ITEM DATE REMARKS/TYPE BY
STREET ]
tW tf1tll AV91A l` -- jl,E
.-OPENED
, ♦l
-
_
ESTIMATED STREET OPENING DATE: �_- 1ESTIMATED STREET CLOSING DATE: / /(3) SECURITY NO. SECURITY AMT: $ luJ,' . ET -Z L � �ILV
SURETY CO.: ED 'li ;CERT)FI6DCHECIS It CASH O C.PLOT PLAN: 1No1cATE SITE PERTINENT PHYSICAL
FEATURES: EXCAVATION LOCATION AND EXTENT. SPECIAL pROVISION!i/CONDITIONS
STIE: 116 3A1 pacul c. H& �4 ,I., ,_tcxt? Sti u_L 1, j X k.
1 1
I I MK7Cic aLEl 1 I 1 _',i I tltal k StSal] cJaLiOcfi t0 City ; 1YI uzis
' _.�_ �_ 1 ► r�ci>icy`'(m; see attadiai.
'URS - 'll� % XXXXXXXXXXX �( XXX
- - �i I` i�/.'y,l . ,,1 1Y8 (1�: utility (-b.
I - - -
I AJ
94 9-/th Avme �i I KB1C7tl.LLI� LtCllr E'tCJ.�. j
-r 1 -- --- - 44)etri s JV311 ijmWi-ately be L-aTmed !:atm i
•C IRs - I ' r �• — _ _ - - , I _ Glrw1c site.
txaff is "mitral :-lull 1�
( I I I } m✓illed fcc at all tillt336.
I I
S)
RIGHT OF-Wr JURISDICTION
THE CITY OF TIGARD DUES NOT, HEREBY, C,RANT PERMISSION TO APPLICANTS 1'p CONDUCT WORK WHERE
15 THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON.
THE APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURITIES, TO CO APLY WITH ALL PERTINENT I AWS ANL)
CONSTRUCTION SPECIFICATIONS PERTINENT T'O CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CIT*, AND
EMPLOYEES AGAINST ANY IN)URY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
APPLICANTS SIGNATURE
9 '—c-7396
CHECK. AMOUNT : 1066. 00
CITY OF T I GARB RE
— CE I F'T OF PAYMENT RECEIPT N �. ��
CASH AMOUNT O��lEl�9
NAME : EMAI , DAVID A. PAYMENT DATE
ADDRESS
1049 SI,J BASELINE, SUITE 420 SUBDIVISION
HILLSBORO, OR
97123—
PAID
AMOUNT PAID PURPOSE OF PAYMENT AMOUNT
PURPOSE OF PAYMENT -- --__0
102 000 PUBLIC IMPROV +C
490 41. 00
CUSTOMER REPO
1
JOY THEATRE
TOTAL AMOUNT PAID —
_ ! DAVID A. EMAMI
1049 S.W.BASELINE SUITE 420 640-6120 6076
HILLSBORO,OREGON 97129
I
'
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l �lJ
PAY TO THE / — —_—_ -- — — Q `� /v
ORDER OF' _1 A ---{jgEU1RS
Wh
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n• K 77
1173 W 6.wliw.S37
Illll.bero,fhr�ow 123
__-- 11�0060 ?6118_ 2300013t L x,6;]8500
CITY OF TIGARD
STREET OPENING PERMIT
APPLICATION
DATE // ? _
• APPLICANT'S NAME l �/] �n. ��! �✓Yl/1�1ttr
ADDRESS � r—SCK 1"
ZIP
PHONE /' C.1 ,)
•
CONTRACTOR'S NAME � .. ✓,n
ADDRESS
ZIP
PHONE
• PLANS BY ��. -
ADDRESS Q
ZIP
PHONE
€'CAS" '7
• DESCRIPTION F WORK PROPOSED TO BE DONE: ' ��CWQ
• ESTIMATED VALUE OF WORK (within public right of-way) : $` Tan @ z•ooa�
• WORK LOCATION/SITE ADDRESS: �� ( 'S14
• -S Tt IIS WORK RELATED TO A LAND-USE ACTION? IF SO SPECIFY (MLP, SDR, ETC.) NO.
• IS THIS RELATED TO A BUILDING PERMIT? IF SO, SPECIFY (BLDG. PERMIT) NO. (Ito(
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