12585 SW PACIFIC HIGHWAY FILE N0.
PACIFIC HWY, - 12585 STR. UPN. PERMIT
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City of Tigard
INSPECTION REQUEST
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for
INSPECTION TIME',±'-^.t PERMIT NO. : -
DATE: -71,� llk'k, DATE ISSUED :_. _I Z
OWNERS NAME :
ADDRESS:
CON TRACTOR : .._.--- - _ -__ -- - ----- i
,'EST : Asir 0, Woter 0 . Visual i, Lab-•.,utory ❑ i
RESULT: Approved X , Disapproved C Pending []
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INSPECTOR DATE
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City of Tigard
INSPECTION REQUEST' �
for
INSPEcvON '.ME: , =„L PERMIT NO. :--
DATE. t4, /JZ DATE ISSUED .__-L—Z
OWNERS NAME: i
ADDRESS: ` pct c �
CONTRACTOR . �� ►u�r{
rEST : Air (3, Water L , `disual , Laboratory of �Y�c471
9ESULT: Approved Disapproved C , PenJing ❑
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ION -- STREr- f IMPRf—MENT/EXCAVATIONI(,,,
PY TO:
WHITE) FILE
ORDINti,, ,:E NO. 74-14 BLUE) INSP.
YELLOW) OTHER AGENCY
;INSTRUCTIONS ON SEPARATE SHEET) PINK) - APPLICANT
APPROVED APPLICATION NO. 41 _
NOT APPROVED CITY O1'TIGARD,OREGON FEE AMT.: S
F LN DING FEE. PMT. ❑ CITY HALL RECEIPT NO.:
PENDING SECURITY ❑ PUBLIC WORKS DEPA R TMEN T BY -,-R-69I DATE /Z /2 7
PENDII.G AGENCY ''OK'' ❑ Application and Progress Record e - / ,+
MAINTENANCE BOPjD4 s�; ex't"
PENDING INFORMATION ❑ FOR STREET IMPHOVEMENT/EXCAVATION As REQUIRED >(-- -
ANNUAL u
PENDING VARIANCEEXPIRATION DATE:
F1 -
--
PERMIT NO - '��" -7 DATE ISSUED: 3Y: _
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL Z'4"'6
- AS DESCRIBED HEREIN. IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT /1 Vh AMIE e , _�nr� � ADDRESS _ CIt _L�/_,.{�rC G PH
CONTRACTOR &0101"a.1
NAM�VS*E'er rs/!•jAOC RE55 /.ZYfIP 5 i!/. fl,.ar lr !T _j. ��- fd SJ
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PLANS BY I /� Hs T-rn C. — f L/�r e &7 .e
NAME ADDRESS 1 Y --'--�- ,�
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ —^1QO --
DOLLARS
(2) EXCAVATION DATA: tLLUD
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STREET DESCRIPTION GRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM 4 QUA
/ T—13
ESTIMATED STREET OPENING DATE: / Z-7ESTIMATEDSTRF-ETCLOSING DATE: 1 Z'7 / 7 7T(3 EryNO15G�7 SECURITY AMT.: S � tT
EDSURETY CO.: Cr r _r l <. �cc "la�r^r. , � L -
CERTIFIED CHECK U___F_A�H �!,O�v.`0 _ INQPEC,
(4) PLOT PLAN INDICATE SITE PERTINENT PHYSICAL r� SPEC'AL PROVISIONS/CONDITIONS:
FEATURES: EXCAVATION LOCATION AFID EXTENT. /
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(5) 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
EMPLOYEE"S AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
'41 ..#Ie
APPL•CANTS SIGNATURE ��`L CGIL.f=�JY`" DATE ;76'--./ 7
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APPLICATION - STREET IMPR( -MENT/EXCAVATION COPY TO:
[� (WHITE)- FILE
ORDINr- ,.CE NO. 74-14 I] (GLUE) -INSP.
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(INSTRUCTIONS ON SEPARATE SHEET) (PINK)
P NK O AGF NCV
APPLICANT
DROVED C7 APPLICATION N'O.: -�
JT APPROVED ❑ CITY OF TIGARU, OREGON FEE AMT.: E _ �_---
PENnING FEE.PMT. ❑ CITY HALL. RECEIPT NO.
PENDING SECURITY ❑ PUBL IC WORKS DEPA R TMEN T BY __ ____ DATE l 1
- - - - - - - - - - - - - - -
PENDING AGENCY "OK" ❑ Application and Progress Record MAINTENANCE BOND #—
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS REQUIRED n
ANNUAL 11
PENDING VARIANCE ❑ EXPIRATION DATE:
PERMIT NO -- - -_ DATE ISSUED: _-
(1) APPLICATION IS HEREBY ;AADE TO EXCAVATE FOR AND INSTALL
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS
t'IPPLICANT
'NAME ADDF' !�— CITV PHONE
CONTRACTOR ---
---- NAME) -- ADORE.SS -- - ----------- ---- CITY ^HONE
PLANS BY
ADORERS---- ---- CITY PHONQ
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST). $ _--
DOLLAR!
DATA: FOR OFFICE USE:
(2) EXCAVATION D — ---- MIN.
_ _ 0.02xf = i—
STREET DESCRIPTION _ PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
_ TYPE LENGTH WIDTH DEPTH ITEM & QUANTITY
STREET
gPEND _
INSPE -
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ESTIMATED STREET OPENING DATE: -�_-L S
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ESTIMATED STREET CLOSING DATE: E
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STREET
(.3) SECURITY NO. __— SECURITY AMT.: $ _ _____- CLOSE
SURETY CO.:
_ CERTIFIED CHECK 'i 4 CASH '1 BOND INSPEL:
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL -ter SPECIAL PROVISIONS/CONDITIONS-
FEATURES: EXCAVATION LOCATION AND EXTENT.
(5) 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 'HE STATE OF OREGON,
THE APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURITIES, YO COMPLY WITH ALL. PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HAFMLESS THE CITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTICINS
APPLICANTS SIGNATURE - DATE / /
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