14915 SW 103RD AVENUE FILE NO. L3(o-$(O
7ncd AVE. - 14915 STR. OPN. PERMIT
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EXPENDITURE REIMBURSEMENT REQUEST A;
This form is a multi-use fora. Where appropriate receiFts must 5e attached.
Documentation is important for ali purposes. Staple documentation to form.
VENDOR N0:
DATE: November 14 , 1986
PAYABLE TO: rhomas J. Bart Requested by: Engineering
_ 14915 S W 103rd Avenue _
Tigard, OR 97223
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MISCELLANEOUS (parking, books, subscriptions, dues, zemberships, etc. ) :
Date i Description Account No. Amount
1 1 / 4 Refund for performance bond 10-220- $250 . 00
_ for permit # 236-86 a 14915 103r ]
Recie t # 136 (5-27-86)
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GENERAL MEAL EXPENSE:
�aLe Description _ _ _ __ Amount
Account Number to be charged: Total
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MILEAGE:
Date Description: (Include end/start readings and total miles) Amount
Account Number: Total ■files x .IO
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APPROPRIATION BALANCE: AS OF: Signature
APPROVALS (if =25.00 or undereimbursed through petty cash) :
(up to $500.00)Section Managerma J r_ - Purch Agent YJ
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APPLICATION - STREET IMPF 'EMENVEXCAVATION COPY TO:
[7 (WHITE)-FILE
OR DIN,,,VCE NO. 74-14 ❑ (YELLOW)-INSP.
(INSTRUCTIONS ON SEPARATE SHEET) ❑ (PINK)-OTHER AGENCY
(BLUE)-APPLICANT
APPROVED S
APPLICATION NO.: `L
NOT APPROVED ❑ CITY OF TIGARD, OREGON FEE AMT.: S
PENDING FEE. PMT. ❑ CITY HALL RECET NO.:
PENDING SECURITY ❑ PUBLIC WORKSDEPARTMF-NT BY / '� _ DATE
PENDING AGENCY ''OK" ❑ Application and Progress Record — M — CGJ h
MAINTENANCE BOND
PENDING INFORMATION ❑ +k_
FOR STREET IMPROVEMENT/EXCAVATION AS REQUIRED
ANNUAL ❑
PENDING VARIANCE ❑ EXPIRATION DATE:
PERMIT NO.: ,�G_=KK{�_ DATE ISSUED: _ s /� Z� �o_ BY: ���_-_____
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
AS DESCRIBED HEREIN, IN PULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT __ ��11:'Y1'i i� IJ _zl K'AL% (v09-
NAME ADDRES! --- - -- `--
CITY PHONE
CONTRACTOR-----.-- _
NAME ADDRE E — CITY _ ONE-
PLANS BY
NAME ADORE!! C17Y PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): E L
—:--. - _.-.--- =_--__ ------- _ __ DOLLARS
(2) EXCAVATION DATA:
FOR OFFICE USF �— ��� Op CMIN.
S 0.04 X S ��51Z_-a s
STREET DESCRIPTION PROGRESS & INSPECTION STATUS _
NAME SURFACE CUT CUT CUT MATERIAL INSTALL[D ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEI TH ITFM A QUANTITY
Ur L Yc-J I L I �'�I r C v1 STREET
INSP
R TIO
Qu
ESTIMATED STREET OPVNING DATE: E
— S
ESTIMATED STREET CLOSING DATE: 1 / T
E
(3) Si CURITY NO.
---.-- SECURITY AMT.: $ A—,�L (' _— CLOSET
SURETY CO.: - _ FINAL 1jL
CERTIFIED CHECK it CASH FOND INSPEC. 4
~ _ /
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS CONDITIONS: ,r
FEATURES; EXCAVATION LJCAIION AND EXTENT. TG /C/ C
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(5) NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSIOF' TO APPLICANT9 TO CONDUCT WORK WHERE
RIGHT-OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNTY uR THE STATE OF O.ZEGON,
THE APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURITIES, TO COMPLY WITH .ALL PERTINCNT LAWS AND
CONSTRUCTION SPECIKICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY AND
n� EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
APPLICANTS SIGNATURE DATE v
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