11632 SW 98TH AVENUE-1 FILE NO. �
98TH AVE. - 11632 STR. OPN, PMlIT
C:
APPLICATION — STREET IMPRr 'CMEN i/EXCAVATION COPY TO:
❑ IWHITE)-FILE
ORDIN. ...CE NO. 74-14 ❑ (BLUE)-INSP,
❑ IYELLOW)-OTHER AGENCY
(INSTRUCTIONS ON SEPARATE SHEET) ❑ (PINK) -APPLICANT
APPROVED' ' APPLICATION NO.:
CITY OF TIGARD OREGON /�
NOT APPROVED ❑ r FEE AMT.: E l�C.-J
PENDING FEE. PMT. ❑ CITY HALL RECEIPT NO
PENDING SECURITY 13PUBL/C WORKS DEPA R TMEN T BY %'l-._._�-.__ DATF__ ..-71_,?Z
–
PENDING AGENCY "OK" ❑ Application and Progress Record -
MAINTENANCE BOND M
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS REQUIRED U
ANNUAL ❑
PENDING VARIANCE ❑ EXPIRATION DATE: /
PERMIT NO.. L_�� _L_ DATE ISSUED:
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
`' If�2'3 �u� I���L AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH
CICITY
�REQUIREr"iENTS.
APPLICANT � QS�_d-)X2Z __G�_-z S,r /LAS � G �L�s�� z -4I?7
NAME ADDRESS CI PHONE
CONT RACT'OR -_ NAME ADDRESS CITYHI HON,- _
PLANS BY _____
- �' NAME -� ADDRRUB CITU PHONE-
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S
_ DOLLARS _ _
(2) EXCAVATION DATA: FOR0F`Fici u --"`— -- aM1N.
0.02 X S �� - l—,✓1� _
STREET _ DESCRIPTION PROGRESS & INSPL:CTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM & QUANTITY
E l�U� �� STREET
�^ Q 1
ESTIIIATEDSTREET OPENIN : DATE: `,_ 7 L 7;' S I R r4-+C, ��f
F�fIMATIE D STREET CLOSING', DATE:
+' ET
(3) SECURITY NO. SECURITYAMT.: E�- `��r'= tSTRE
CLOSED
SUF,,ETY CO.: _ FINAL
CERTIFIED CHECK D CAB BOND O INSPEC.
(4) PLC1T PLAN: INDICATE SITE PERTINENT PHYSICAL. SPECIAL PROVISIONS/CONDITIONS:
FEATURES; EXCAVATION LOCATION AND E:CTENT LIC�JJ�]�
CURB
-
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1 1 1
(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 PERTINF T._TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINST ANY INJURY OR DA G�k HICH M ESULT FROM APPLICANTS ACTIONS.
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APPLICANTS SIGNATURE. `t'�'I 0 i_ DATE
� ~ 7F
CITY OF TIGARD- 12420 S.W.MAIN-TIGARD,OREGON 97223
RECEIPT
DATE: a ' 7' •MOUNT: S
-c �\M.c.�.t� � , < t,L •C �T- --DOLLARS •{ t
NAME: _ /--�°-GC=a. : t� i.•� CASH:
ADDRESS:_.._.1a/ �/ �.`" ,;`r ,�y .cr�J''�.. �-C CK:
7 3-a 1/' M.O.:
+► OF
FOR: ACCT. N PERMIT! SURCHARA! AMOUNT
SEWER BILLINGS 40-364 _ $
BUSINESS LICENSE 05-331
PLUMBING PERMIT 05-332 S----
MECHANICAL
-_-MECHANICAL PERMIT 05-332 —
BUILDING PERMIT 05-333
SEWER CONNECTION 40-363 _-___-____
SEWER INSPECTION 40-365
SYSI EM DEV.CHARGE 25-366
t PARK DEV.CHARGE *1 30-367
PARK DEV. CHARGE 42 30-368
ZONING ADJUSTMENTS 05-362 _
TOTALS
RECEIVED BY:
PERMIT NUMBERS ASSIGNED! r^
Numbor Amount Numbw Amount Numbw Amount
S
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- Ric"PT N 0
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{if x I+Mxi y Iw
77
APPLICATION — STREET IMPF' 'IEMENT/EXCAVATION COPY TO:
ORDh_NCE NO. 74-14 ❑ (BLIT)--PILE
❑ (BLUE)-Infr.
(INSTRUCTIONS ON SEPARATE SHEET) ❑ (YELLOW-A -OTHER ACLNcv
-PINKK)) APPLICANT
DROVED ❑ APPLICATION NO.-
NOT APPROVED ❑ CITY OF TIGARD, OREGON FEE AMT.: S_
PENDING FEE. PMT. ❑ CITY HALL RECEIPT NO.: -
PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT BY DATE
PENDING AGENCY "OK" ❑ Application and Progress Record
PENDING INFORMATION ❑ MAINTENANCE BOND IK
FON STREET IMPROVEMENT/EXCAVATION L5 REUQUIRED ❑
ANN AL
PENDING VARIANCE ❑ EXPIRATION DATE:
PERMIT NO.: _. DATE ISSUED:
(1) APPLICATION IS HEREBY MANE TO EXCAVATE FOR AND INSTALL
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT- —
_ NAME ADDRESS
CONTRACTOR
NAME ADDRESS CITY �..__ - ►HONE
PLANS BY NAME - - ADDREfC
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S
DOLLARS
( CAVATION DATA: POR OFFICE UfE: aMIN.
2) EX
0.02x9 =s�
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUY CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM AI QUANTITY
STREET
-D
INS
6 TION
U
ESTIMATED STREET OPENING DATE:_ (_ / S
ESTIMATED STREET CLOSING DATE: —1 E
STREET
(3) SECURITY NO. SECURITY AMT.: S CLOSE
SURETY CO.: FINAL
CERTIFIED CHECK ❑ CASH ❑ BOND o INSPEC.
(4) PLOT PLAN: INDICATL SITE PERTINENT P14YSICAL SPECIAL PROVISIONS/CONDITIONS:
FEATURES, EXCAVATION LOCPTION AND EXTENT.
1 ( I 1
,08
it1 I I 1
1 1 1 1
I I I I
I I I
-I NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHI<11E
RIGHT OF-WAY JURISDICTION IS THAT OF WASHINGTON CC LINTY 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.
APPLICANTS SIGNATURE; DATE 1 1
J
f
city of Tigard
INSPECTION REQU` ST
for
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