14880 SW 92ND AVENUE-1 FILE NO. ZOO-� ,,
92ND AVENUE - 14880 STR. OPN. PERMIT
APPLICATION - STREET IMPROIE NVEXCAVATION *(PINK)
COPY TO:
ORDINA : NO. ]4-14WHITE)-FILE
YELLOW)-INSP.
(INSTRUCTIONS ON SEPARATE SHEET) -OTHER AGENCY
BLUE)-APPLICANT
APPROVED
NOT APPROVED CITY OF T'IGARD, OREGON APPLICATION NO.:
FEE AMT.: fj�_-_�
PENDING FEE. PMT. CITY HALL
RECEI T 2p/M,
PENDING SECURITY U) PUBLIC WORKS DEPARTMENT BY /` p
— DA7E- T
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PENDING AGENCY "OK" [; :Application and Progress Record – – – – – – – –
PENDING INFORMATION C1 FOR STREET IMPROVEMENT/EXCAVATION MAINTENANCE BONN
AS RE(.IUIREU —
PENDING VARIANCE ❑ ANNUAL- p
EXPIRATIO DATE:
PERMIT NO, Z Sd `8$� DATE ISSUED 1.4 '� BY _
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL_
_ AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH TY RIE UIIREMENTS.
APPLICANT - -�-' I _ __!`L�<--' G' C; •�� (�/,(<' , C�.�l'� ,G'�a
� NAMES AODRE gl
CONTRACTOR �n <� � ��U
�'�' " AM! AD MESS ITY
PLANS F3 Y ---��-�--• —moo N
J NAMEAREf JIG.C/
CITY PHON
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): : _ _
DOLLARS
(2) EXCAVATION DATA FOR oFFlci:uf[�
0.04 X III
Z�C�
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED
TYPE LENGTH WIDTH DEPTH ITEM A gUANTITV ITEM DATE REMARKS/TYPE BY
i
11C. l r L � STREET
PEN
INSPE -
R TION
E -
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ESTIMATED STREET OPENING DATE: (_ I
ESTIMATED STREET CLOSING DATE. _ TNI E� S
_ / T _
E
(3) SECURITY NO. SE _ . �� STREET
SURETY CO.: _
T: S T CLOSE
CERTIFIEDC_[ FINAL t`
----- - •oN�D r INSPEC. /-�- •� C
(4) PLOT PLAN- INDICATE SITE PERTINENT PHYSICAL t
FEATURES: E.,CAVATION LOCATION AND EXTENT, SPECIAL PROVISIONS/CONDITIONS
UAB
N39 (dr) Mo-,
J 11 s _7%
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(5I 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
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
r�APPLICANTS SIGNATURE�
PLEASE TAKE THIS TO THE CASHIER FOR A RECEIPT
I I
DATE:-2 4 —,cv,
H DESCRIPTION — AMOUNT
r�2000 1 Refundable Performance Bond Deposit a�
43500 — Sign Permits HOP TU $
(�r
3600 Public Sewer Plan Check/Inspection Fee__ $—
, 3'600 Public Storm Plan Check/Inspection Fee $
f ` —
A3600 Street Dedication/Public Improvement Fee $
6p0=— Street Opening Permit $ ,
, 3601_ Street and Traffic Marking
f!
4200 _ Street Light Fee
X13700 Subdivision Applications:
S MLP
/13^00 Zoning Applications:
ZC CPA ZOA PD Misc
SCE CU SLP V $
,44000 Other Planning Fees:
SDR
Non refundable portion of Appeal Fees $
/L000Refundable portion of Appeal Fees $
A5100 Document Sales:
Engrg. PlanningBldg. _ $
,+3000 Business Tax $
TOTAL $
,.OP/0023P
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CITY OF 716AMM No. 28916
13125 S.W• HALL BLVD.
P.O.BOX 23397 Date..
TIGARD,OR
97223
-2 U,
Name �M
Address
Lot Block/Map Subdivision/Address
Permit M's Bldg.
Plumb Cas ��
the–r-- Ae,,
S
- Other
ewer �
Ai fitDescription
Acct. No. _• _�—
10.432 Building Perm iI Fees
_ _
10-431.600 Plumbin Permit Fees --------
10-431-601
____10.431.601 Mechanical Permit Fees
10.230-501 State Bid
F. Tax
10.433 Plans Chee _
30.443 Sewer Connection
30.444 Sewer Inspection
51-446 Street S st. Dev. Char e
52.449.610 Parks I Syst. Dev. Char e
52.449.620 Parks II Syst. Dev. Charge
31.450 Storm Drainage Syst. Dev. Charge
10.430 Business Tax
10.434 Alarm Permit
-10.227 Bail
10.455- _ Fines • TrafficimisdlParking
10.230- CPTA TrafficlMisdlVic. Asst.
10.456 Indigent Defense
30.122.401 Sewer Service,USA
30-122.402 Sewer Servi– ce/City 30%
0-123 Sewer S— ev�cel Ity Maint.
3 •12 Unmatched
31.124 form Drainage
4 .475 Bancroft Prin. Pymt.
4 -471 ancroft Int. Pymt.
1 �
TOTAL
ACCOUNTING COPY
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CITY T T16A RD
EXPENDITURE REIMBURSEMENT REQUEST
1
6
This form is a multi-use form. Where appropriate receipts must be attached.
Documentation is important for .ill purposes. Staple documentation to form.
VENDOR NO: DATE:_
PAYABLE T0: 1y1S�o, 1�0 Requested by: _
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MISCELLANEOUS (parking, books, subscriptions, dues, memberships, etc. ) :
Date Description Account No. Amount -
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GENERAL MEAT. EXPENSE:
-Date Description Amount
Account Number to be charged: xave. Total
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MILEAGE:
Date Description: (Include end/start readings and total miles) Amount
i Account Number: Totalmites x$.21
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APPROPRIATION BALANCE: �A5 OF: _ Signature
APPROVALS (if $25.00 or under may be reimbursed througi petty cash) :
(up to s500.00)Section Manager _ Pu :ch. Agent
($500.01-$5,000.00)Dept. Bead/Purch. Agent z
�To 14
IL
�41