11495 SW 92ND AVENUE i
FILE NO. I
92ND AVE. - 11495 S'l'R. OPN. PERMIT
APPLICATION — STREET IMPRr 'CMENT/EXCAVATION COPY TO:
ORDIN. ...CE NO. 74.14 [j (BLUE) -INSP.
(INSTRUCTIONS ON SEPARATE SHEET) L� (YELLOWI OTHER AGENCY
n (PINK) -APPLICANT
APPROVED I APPLICATION NO.: _ IS Z_
NOT APPROVED ❑ CITY OF TIGARD, OREGON
FEE AMT.: i
PENDING FEE PMT. ❑ CITY HALL. RECEIPT O.: 3 __
PENDING EECURITY ❑ PUBLICWORKS DEP'ARTMEN7 BYDATE
_ aL�s/�l
PENDING AGENCY ''OK" ❑ Application and Progress Record — — — — — — — r
MAIN''tNANCE BOND N S �3�''S
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS REQUIRED
ANNUAL C]
PENDING VARIANCE EXPI RATION DATE: /
PERMIT NO. - b I_- - _.. DATE ISSUED: SL) — _ j _ . BY:
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL_ __ ..���'•' ft r" S�<� ��
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH ZITY REQUIREMENTS.
APPLICANT _ � F�'c Kp U SS ON) .4m) 2amrh4i." Tt 6�6200�
N E --'--Ipo [ss 1 NON
CONTRACTOR f ( '7t � _ I, DLf��'Im ����
ADDRESS
PLANS BY _ � C/ re'l ( �>'( f � �! c t` ^ H o��r� ��/
ADDRESS _ll CITY —�1 N/ ONE fE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ ) /e _
DOLLARS
.� FOR OFFICE USE! _ ❑MIN
(2) EXCAVATION DATA.
STREET DESCRIPTION PROGRESS & INSPECTION STATUS _
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM !! QUANTITY
STREET
N D
!Z lIr 2 ( R TION -
Q
U _
ESTIMATED STREET OPENING DATE:_..._.� L, / E
ESTIMATED STREET CLOSING DATE: / T
_ E
D
(3) SECURITYNlOS -3L ' 1- URlTY AMT.: $ clT.osET
SURETY CO.: � tl n F{_ FINAL --
_ C[RTIFI[O CM[GK CJ CASH ❑ INSPEC.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL- SPECIAL PROVISIONS/CONDITIONS
FEA R ; EX AVATION LO ATION AND XTENT,
17 w /
I l�N is
1 1 1 I 1
(5) NOTE THE CITY OP TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT-OF WAY JURISDICTION IS THAT OF WAnHINGTON 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 ANb
EMPL,YEES AGAINST ANY IN AY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTION4
r
APPLICANTS SIGNATURE: ` ' J� 7 DATE
CITY OF TIGARD—12420 S.W.MAIN—TIGARD,OREGON 97223
RECEIPT
DATE: S % S� -AMOUNT: $
LLARS
NA0CASH: . .
ADDRESS: �� r'' CHECK:
J �
M.O.:
# OF
FOR: ACCT. N PERMITS SURCHARGE _AMOUNT
SEWER BILLINGS 40-364 S
BUSINESS LICENSE 05-331
PLUMBING PERMIT 05.332 S
MECHANICAL PERMIT 05-332
BUILDING PERMIT 05-333
SEWER CONNECTION 40-363 r
SEWER INSPECTION 40-365
SYSTEM DEV.CHARGE 25-366
PARK DEV.CHARGE #1 30-361 _
PARK DEV CHARGE #2 30-368 _
ZONING ADJUSTMENTS 05-362
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--- --- TOTALS
,F('FIVFD 1iY
PERMIT
Number Amount Number Amount Number Amount
S - ----
S--
S----
S--- RECEIPT N
9364
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