14820 SW 109TH AVENUE FILE NO. 3ti(,-&9
109TH AVENUE - 14820 STR. OPN. PERMIT
I
ar W TIGAIM
EXPENDITURE REIMBURSEMENT REQUEST
This form is a multi-use form. Where appropriate re :eipts must be at::ached. ,
Documentation is important for all purposes. Staple documentation to form.
VENDOR NO: 1 DATE: O —S;�
PAYAB).E TO: aV 1(A �\���vv\ Reque;ted by:
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11
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MISCELLANEOUS (parking, books, subscriptions, dues, m:mberships, etc. ) :
Date Description_ AccoLIt No. -� Arount
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GENERAL MEAL EXPENSE:
Date Description Amount
i Account Number to be charged: Total
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MILEAGE:
a—anMILEAGE:
Date Description: (Include end/start readies and toi:al miles) Amount -
i Account Number: Total miles x$.21
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APPROPRIATION BALANCE: AS OF': Signature
APPROVALS (if $25.00 or under i ,y he reimbursed through petty cash) :
(yip to W0.00)Section Manager Purch. Agent
($500.01-$5,000.00)Dept_. Head/riirch. Agent
r
INSPECTION NOTICE
City of Tigard , ing Department
P.O. Box 23397
Tigard, Oregon 97223
Phone: 639-4175 /
Type of Inspection _�, , c" �C--
Dare Requested Time A.M. _P.M.
Address 1 /r --. zj') Permit # f
Owner_- Lot #
Builder �� 1�
The following Building Code deficiencies are required to be corrected:
i
- i
- i
Presented to ---- — —I-; Approved - -----
Inspector pe t �. Disapproved
Dote
CLL FOR REINSP ON
[] YES NO
APPLICATION - STREET IMPRO" 1/ENT/EXCAVATION To:
FILE
ORDINA .,.E NO. 74-14 C_ ( U�
YELLOW)
)-•INSP.
(INSTRUCTIONS ON GEPANATE SHEET) ❑ LBW KI-OTHER AGENCY
V-FBLUE)-APPLICANT
APPROVED APPLICATION NO.: J?19 L _
NOT APPROVED ❑ CITY OF TIGARD, OREGON FEE AMT.. S IVC7
PENDING FEE. PMT. ❑ CITY HALL RECEIPT NO.:
PENDING SECURITY ❑ PUBL IC WO R KS DEPA I?TMEN T BY' C 'e- DATE__ ZL- 4C_
PENDING AGENCY "OK" ❑ :application and Progress Record
PENDING INFORMATION ❑
FOR STREET IMPROVEMENT/EXCAVATION MAItI
NTE REEooNO .
ANNUAL
PENDING VnRIANCELl
�/ EXPIRATION DATE:
PERMIT NO 7 DATE ISSUED: I )I _•I"_ BY __ -,--
-
(1 ) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
/- ��`! r'` A�� AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH
\CITY REQUIREMENTS.
APF'LICAN – AMIV�� ADi u—LCL�lr1/�F � _N•� 1 ) �Z,�f�3
COf�TR .%.'TOF Uj _�,_mIN�'1 e�1�S1, ar C,o�ED �Q ' v1 �!CITY _�l2i_ ,�zQ3
NAM! A DR
PLANS BY
?JAM t ADDRESS CITY
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST,: ; 4yc' ' C o _
T
DOLLARS
(2) EXCAVATION DATA: -- FOR OPFICE fE
0.04 X S_m-v=J = S coy
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE I CUT CUT CUT MATERIAL INSTALLED ITEM
TYPE_ LENGTH WIDTH DEPTH ITEM d QUANTITY DATE REMARKS/TYPE BY
�IU- I DTll ^ 1 Rsot STREET
P NED
INSPEC
R TION
G
ESTIMATED ,PENING DATE:-,,. E
ESTIMATED STREET CLOSING DATE: --- T
E
(3) SECURITY NO. _ SECURITY AMT.: D�> STREET
CLOSED
SURETY CO.: FINAL
CERTIFIED CHt�:K tr
CASH ❑ •OND r,- INSPEC.
(4) PLOT PLAN INDICATE SITE PERTINENT PHYSICAL i SPECIAL PROVISIONS CONDITIONS
FEATURES: EXCAVATION LOCATION AND EXTENT.
��a-;� 1`. _ _ _ _ __., ��Z� _ __ �I �a _ �- ,��•�.�
1 I 1
I I I
r1) NOTI' THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APrLICANTS TO CONDUCT WORK WHERE
RIGAT OF-WAY JURISDICTION 15 THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON.
THE APPLICANT AGREES TO DEPOSIT THE RCQUIRED SECURI CIES, f0 COMPLY W,TH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY AND
MPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS
AF'I'11( nNTk. SIGNATURE r
_ DATE I
-'-)F' TIGAPD RECEIPT OF PAYMENT RV i C N 001 CJ5 45.":'f
CHECK AMOUNT s 4' 1C,. OU
W A M F-, DAVID 11.1.1-IM (A)P151"T CIAGH AMOUNT t . 00 1
ADDRESS: 2-1-700 COVE 0RU-4AFt RD NE' PAYMENT DATE n 0 12°'.•.H9
,rAPlHlLf-, OR
1116'20 'SW IL191H
PtIRFOSL Pi=+oiuq-r AMOUNT PAID F'URF'Oc:jE OF PAYMENT (-MOUNT F.,('.ilrj
CUSJCJMFP [IF-.F,OST'('-, 400. 00 FLI[A-IC IMPROVEM t'7,91i 16. CIO
II
TOTAL AMOUNT FAIL, 00