15905 15915 SW 79TH AVENUE FILE NO. 41twp5- -8-1
79TH AVE. -- 15905 & 15 STR. OPN. PERMIT
CiTYOF TIIFAIW
EXPENDITURE REIMBURSEMENT REQUEST
This form is a multi-use form. Where apprrpr"iatc receipre must be attached.
Documentation is important for all purposes. Szaplc documentation to form.
VENDOR NO: DATE: I — Z
PAYABLE T0: -V �i1 `Jco LO�n� u�}�ov� Requested b;,:
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MISCELLANEOUS (parking, books, subscriptions, dues, memberships, etc.):
Date _Description Account No. Amo. i
,.nom + Sura"ke e c T 100(), CV
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GENERAL MF..AL EXPENSE:
-Datel Description Amount
Account Number to be charged: Total a
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MILEAGE:
Date Description: (Include end/start readings and total miles) Amount
Account Number: �._ Total_ wiles x$.21 a
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APPR0 RI.ITION BALANCE: AS OF: Signature
APPROVALS (if $25.00 or under may be reimbursed through petty cash) :
- 14 - 41''
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APPLICATION - STREET IMPR cMENT/EXCAVATIO! tp(,
Y TO.
ORDIN-4CE NO 74-14 YELLO • -IN
(YELLOW)•(NSP.
(INSTRUCTIONS ON SEPARATE SHEET' ❑ (PINK)-OTHER AGENCY
Y<BLUE)-APPLICANT
APPROVED w APPLICATION NO.: �Q
NOT APPROVED /❑ I I Y OF TIGARD, OREGON FEE AMT.: S
PENDING FEE PMT. Ej CITY HALT. RECEIP . _ 2-4-701
PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT BY - DATE � I it I&
PENDING AGENCY "OK" ❑ .application and Progress Record —
PENDING INrORMATION El FOR STREET IMPROVEMENT/EXCAVATION MAI AS REQNICREBOND! s
ANNUAL E
PENDING VARIANCE: EYPIRATI ND TE:
PERMIT NO j / , DATE ISSUED. 17 3Y:
r (1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL i!ZY NoARb CLRe�—� S/Z:'d:7 W,<AlpAS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT �AA,__45C04 9z-Sr55 Srw, Zhet� S; ' �r39-4'799
NAME A11DR[! CITY �� PHONE
CONTRACTOR5�2►M___e�____--
NAME ADDRESS ITV - PHONE
PLANS BY___ - � zv. IA I
NAM ADD ESS CITY PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S
DOLLARS
(2) EXCAVATION DATA Pow nPPlc[ulE:— r.MIN.
0.04 X f
STREET DESCRIPTION PROGRESS & INSPECTION S 7 ATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM dt QUANTITY
OPENEDSTREET
ESTIMATED STREET OPENING DATE:� 1 � _— _ ES
ESTIMATED STREET CLOSING DATE: / 1_. g
(3) SECURITY NO. c-ECURITY AMT: S j YWv c�OSEo
SURETY CO.: FINAL M
-- - --
�d CHECK
'ASH o BOND c INSPEC.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL t Y SPECIAL PROVISIONP CtiNOITIONS
FEATURES; EXCAVATION LOCATION AND EXTENT.
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(S) NOTE THE CITY OF TIGARD ODES NOT, HEREBY, GRANT PERMISSION TG 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 REQU..tED SECURITIES. TC COMPLY WITH ALL PERTINENT LAWS AND
CONS i RUCTION SPECIFICATIONS PERTINENT TO CONDUCT of THE WORK, AND TO SAV'_" HARMLESS THE CITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
APPLICANTS SIGNATURE �
DATE
PLEASE TAKE THIS TO THE CACHIER FOR A RECEIPT
NAME: —. I l� Lp'..A — DATE: __15 _/ % --1512 7
ACCT. q DESCRIPTION AMOU►'-
10-22000 Refundable Performance Bond Depc - it:
10-43500 Sign Permits HOP TU $_
10-43600 Public Sewer Plan Check/Inspection Fee $
10-43600 Public Storm Plan Check/Inspection Fee $
10-43600 Street Dedication/Public Improve ant Fee $_
Wit?
10-43600 ___ Street Opening Permit Z-4,5 -T $ _
10-43601 Street and Traffic Marking $
21-44200 Street Light Fee $
10--43700 Subdivision Application--
s '"Ir 237
RCONSTRUG-TION j�
9259
BILL SCOTT A
5TIGARSAN INEZ Sr' �y�1
D OREGON 9122A
$ ° y� e
PAY TO THE --- �T NU .r-�'� -_.. _
orLLARS
ORDER OF
10-21 ird
10-4! vivo go
1 U-a 3 7 0 00 io 237
2 90 i _------ `� s ----
01 A $ 1SG_Zt!c
1045P/0023P
i
/ No. 24701
C1TT1F"�JF Ti��iRD
^ _•' 13125 S W HALL BLVD. ;
P.O. BOX 23397 Date..
TIGARD.OR 97223
/
Name
Address
Lot --TBlocklMap 5ubdivisionlAddress
Ws -�lu Cash Check
I Permit M s Blcg. F,..mb
Sewer Other Other _ Rec. By
Acct. No.
Descr!otion 1 Amou�,1
10-432 Buildin Permit Fees
10-431-600 Plumbing Permit Fees ----
10 431 "` Mechanical Permit Fees_ —
10.2:0-501 5r�to Bldg• Tax _
10.x33 Pla,is Chec:c Fee________.__
30.443 Sewer Connectlon _
30..44 Sewer Inspection --
51-n4e. I Stre_ et SYst. Dev. Charge___
52.448-•6100 Parks_I Syst.DDev. Charge - I
-5-2.449620 F-arks II Syst. Dov. Charge
31 450 ----- torm Drainage Syst. Deo. Charge
10.430 Business Tax _ r
10-434 Alarm Permit ---
10.227 Bail-- _ _ --
F30.122-402
Fines - TrafflclMlsdlParking
C"TA Traffi�IMIsdIVic. Asst.
-- - Indigdnt Dcfense
.401 Sewer Ser,rlce!USA _
Sewer ServicelC:ty 30%
ewer UnmatchSform Drainage
Bancroft Prin. ymt.
40.471 gancro t Int. ymt.
- 7- ��t�s-tt 7 ��—.__TOTAL ,•
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