12550 SW PATHFINDER COURT FILE NO. ',��
PATHFINDER CT.. - 12550 STR. OPN. PERM=
k-1 I Y ur IIrARD
EXPLNDITURE REIMBURSEMENT REQUEST
This form is a multi-use form. Where appropriate receipts must be attached.
Documentation is important for all purposes. Staple documentation to form.
VENDOR NO: DATE: June 4, 1181)
PAYABLE TO: Michael E. Regan Requested by: r-„mmnnit4j npvplopmect
_ 1738 Oak Street
Lake Oswego, OR 97034 v
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MISCELLANEOUS (parking, books, subscriptions, dues, membership , e. c. ) :
Date Description .__ Accounr. No. Amount
6/1/. Refund ut Performance Bond for Street 16 - Q _ 5 011-0ti
Opening Permit #192-84, issued 8/29/84
........................==n•e=:=s==a==========r=====_=====w==========wn=====__
GENERAL MEAL EXPENSE:
Date Description Amount _
Account Number to be charged: _ To-al _
...............=..a===.=.=-==........... =____..____=====u==w==
MILEAGE:
Date Description: (Include end/start readi .igs and total miles) Amount
Account Number: _ TotalT miles x
......................r.a====.........1.........u................
s==.=___
APPROPRIATION BALANCE: 500.00 AS OF: 8/29/HA. SiFnature�-----
APPROVALS ( if $25.00 or under may 0effimb reed th 44h petty .ash) :
(up to $500.00)Section Manager /�t '!� ` tttcCh. Agent I_
APPLICATION STREET IMPRI MENT/EXCAVATION! COPY TO:
U (WHITE! -FILE
ORDINANCE NO 74-14 ❑ ISLUF) INSP.
❑ (YELLOW) -OTHHR AGENCY
(INSTRUCTIONS ON SEPARATE.SHEET', ❑ (PINK) APPLICANT
APPROVED i APPLICATION NO..:
NOT APPROVED CI71 O TIGARD, OREGON FEE AMT.: I-I,,71).
EJ CITY _�- ----- --
PENDING FEE PMT. CITY HALL. RECEIPT MO.: -O.: �CQL__a._.�.--
PENDING SECURITY ❑ PUBLIC WORKSnEPARTMENT BYPnl__ DATE
�L _ _ _/_
PENDING AGENCY "OK" [J Application and Progress kccord
MAINTENANCE BOND M
PENDING INFORMATION L7 FOR STREET IMPROVEMENT/EXCAVATION ASRF.IuIRED
A N N 1,AL
PENDING VARIANCE ❑ EXPIRATION DATE:
PERMIT NO.: L _'_ TATE ISSUED: .__ __ham ZLt y;
_ —sem
(1) APPLICATION IS HEREBY MADE TO EY.CAVATE FOR AND INSTALL
—__ ASZC4, a
CRIED HEREIN, IN FULL ACCORDANCE WITH CITY REQu IR MENTS.
APPLICANT / F .1
QNAME_ A DRESSr tV PHONE
CONTRACTOR 11�� C�U►'I Y`iJ� C_CwtcO-f t C_ 313 St R�_ m -t)A -ie,(
A ACOREt�1—� CITY PHONE
PLANS BY '. rV&–.!
f"AM9 ADORtIS CITVPHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S 500 —_
DOLLARS
(2) EXCAVATION DATA: FOR oFElcc utt: MIN.
_ o.o x s
STREET DESCRIPTION PROGRESS & INSPECTION STATUS_
NAME SURF-ACE CUT CUT CUT MATERIAL IINSTALLED ITEM rATE REMARKS/TYt E BY
I- TYPE LENGTH WIDTH DEPTH ITEM A QUANTITY
S 0J �� ErJ�� STREET
OPENED
INSP C-
R TION
/ QU -
ESTIMA"i ED STREET OPENING DATE: �) _ S _
ESTIMATED STNIKST CLOSING DATE:
D - ----
STREET
13) SECURITY NO. — SECURITY AMT. $ CLOSE
SUPE-i Y CO.: FINAL -
- — —'— EC.
CERTIFIED CHECK P❑ CASH� sOND ..I 1NSP !e _
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL r SPECIAL PROVISIONS/CO''.#ITIC NS:
FEATURES; EXCAVATION LOCATION AND EXTENT. f�I}ti�I / %/ _
I !�^5�1 .Sw I�1` I 1 l�
1
125 , a I ��r�. 7)-d: L" C " .(I
1 1 I I
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(5) NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHNOF WAY JU'ZISDICTION IS THAT OF WASHINGTON COUNTY OR TFIE 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 C17Y AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT 7'ROM APPLICANTS ACTIONS.
Y 7
APPLICANTS SIGNATUI1119: _J 1�. L ,,�,�G _._� DATE
�t
CITY OF TIGARD—12420 S.W.Ma —TIGARD,OREGON 97223
RECEIPT
AMOON T _e, .
( �---- DOLLARS
NAME:
CASH.- ,
ADDRESS:
O CHECK:
--E — ,-- Zn.�J rf MO.:
FOR: r IOP —
_. ACCT. I PERMITS fURCNAROE AMOUNT
SEWER BILLINGS 40-364 _ iS
BUSINESS LICENSE 05-331
PLUMPING PERMIT 05-332 g
MECHANICAL PERMIT 05-332 _ --
BUILDING PERMIT 03-333
SEWER CONNECTION 40.363
SEWER INS4CTION 40-365
SYSTEM DEV. CHARGE 25-366
PARK DEV. CHARGE #1 30-361
PARK DFV.CHARGE +2 30-368
ZONING ADJUSTMENTS 05-362
AZT
--
U�� TOTALS
RECEIVED BY -_ _
PERMIT NUMBERS IONED: —
Number A ount I Number Amount Number
Amount
S ----– S
S $
--
RECEIPT 20129