13620 SW 110TH AVENUE-1 FILE NO,
110TH AVENUE - 13620 STK. OPN. PERMIT
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CIT6 JFTIC-AIM
EXPENDITURE RFT%BURSEMENT REQUEST
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v This form is a multi-use form. '.there appropriate -ec:eipts must h.: attached.
Documentation is important for all purposes. Staple documentation to form.
VENDCR NO: - DATE: l =__~
PAYAB E TO: r1a� CG w
�. Z� � r �ar�_ioy� Requested by:
-MUM s-a--neraoecccssccccrccccccd=ccccccc-ccccccacr_nccl..ncccrannaccccm-----comcccos
MISCELLANEOUS (parking, books, subscriptions, di,c memberships, etc.) :
Dp.te D�!scri :Cion Ac^ount No. _ Amount
_tet-ns_c _+o r ,z�tss- z.2 000
_ <oGad `211
o��,�11--,.x,1 o010sz -S _
c1IVe.A 9-S -meq
w........... ------.--------- cvean acccca.......:cnccc.. ..........................�
GENERAL MEAL EXPENSE:
-Date Description _ Amount
Account: Numher to be c`iarged: _ � - Total
�e�>euvn�.la�vvsl.l
------------- =c-em-etc==�.rc�vc-... ........................f.0�0�
MILEAGE:
Date Description: (Include end/start readings and total miles) Amount
I Account Number: Tota I- m: les x$.21 r1
................... .. —c1 7T;;m _m ccncc _rra..:�,a
APPROPRIATION BALANCE: AS 0F: - Signature
APPROVALS (if $25.00 or under r,:iy. I c re wlmy ! evd throu,,n petty cash) :
(up to $500.00)Section Manager Pr rch. Ap,ent
(3500.01--=5,000.00)Dept. Head/Porch. Agent
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APPLICATION — STREET IMPRC 1ENT/EXCAVATIONc PY TO:
ORDINANCE NO. 74-14 (WHITE)-FILE
(YELLOW)-INSP.
(INSTRUCTIONS ON SEPARATE SHEET) CJ (PINK)-OTHER AGENCY
(BLUE)-APPLICANT
APPROVED
T I AF>PI-ICO TION NO
NOT APPROVED CITY OF TIGARD, OREGON FEE AMT. S _ `
PENDING FEE. PMT. CITU HALL 1 RECEIPT cl. GOo/G'.5 Z/3
PENDING SECURITY ❑ PUBLIC. WORKS DEPARTMENT BY �
_ - � DATE_L_
PENDING AGENCY "OK" ❑ Application and Progress Record
PENDING INFORMATION 0 FOR STREET IMPROVEMENT/EXCAVATION MAINASEREAQNC
UIRE Dor x_ED
.-_ _
PENDING VARIANCE (] ANNUAL
EXPIRATI N DATE: [moi_
-339 -V9
PERMIT NO -3 ISSUED C) cs9 _ BY
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL - _.�'C-,.zc.Lpi-t1.Sa0.
t•
--- _ AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH
GCITY R QUIREMENTS.
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NAME _--ltj-!L.-TTL F
Y /� ADDHESS CIT '
CON� c�i f3`R,� R� /i�?-� l'i �'� Sof• i:Z S-
ADDRESS
�� NAM7t ADDRES!
PLANS BY f E' � �/I'�r �/f(� CITY PHONE
NAi16 ADDRE!! CITY —
�HONE
ESTIMATED IMPROVEMEN-F TJTAL VALJATION ( COST): $
DOLLAR!
(2) EXCAVATION DATA: qAED
ROPFIC&FS-CA4 X S �oNS
STRE,4T DESCRIPTIONPROGRF_SS & INSP'-CTION STATUS
NAME SUFACTYPE E LENCrTH WIDTH DEPTH M TEM IAT LL
/TYPE BY
TEM DATE RE.AARKSREETal PFN .SPEC-
TIONa �ESTIMATED STREET OPENIN�s OATE: / / E --
ESTIMATED STREET CLOSIN i DATE: / / T S
E
D
(3) SECURITY NO. __.__ SECURITY AMT.: _ �IJO.� STPEFT
SURETY CO.. CLOSED
'o ,,,67
F I N A L
MSIR cHscFc cAlH ❑ lOND SPECINSIAL vROV131 /� �Yr� !!�4
(4) PLOT PLAN: INDICATE SITE PERTIN PHYSICAL — ff
-
FFATURES: EXCAVATION LOCATION AND EXTENT. . ON /CO DI IONS:
iso 1_- '
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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 TH:T OF WASHINGTON COUNTY OR THE STATE OF OREGON.
THE APPLICANT AGREES TO DEP,JSIT THE REQUIRED SECUR;TIES, T'O COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THS CITY AND
EMPLOYEES AGAINST ANY INJUFi OR DAMAGE WHICH MAY RESULT VROM APP'.ICANTS ACTIONS.
APPLICANTS SIGNATURE //I 'I•-� "—
DATE
CITY OF TIGARE RECEIPT OF PAYMENT FEC NO: 0("i1i"
CHEEP:: AMOIJF-1'7.
NAME: HALIFI4x CORPORATION CASH AMOUNT • Llb
ADDRESS: 647-12 SE FOSTER E�LPAYMEWF DATE
PORTLAND. OF` L772'%:16 1400'nDR:
F-UPPOSE OF F!'AYMF.-.NT AMOUNT PAID PURPOSE OF PAYMENT AMOUN'r F 4 T I
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-------------------------- ----- -----------
CUSTOMER DEFOSITS 600-00 PUBLIC 111PROVE111 r771=?--6`10) .2 4. 0 1)
THANK-YOU
TOTAL AMOUNT f-kili,
HALIFAX CORPORATION091
1230 5140
6432 SE FOSTEh 774-8891
PORTLAND, OR 97206
)AY 0
TO THE
us.
LLEL"K HALIFAX CORPORATION
Ef STFORT PLAZA BRANCH
1,") BOX a GOWN. PORILAND. On 97266
UNITrO%TATKIII NATIONAL HANK OF ORFO.-
4
1110(1 � onnv o: Lpinnnpdni: nriL nnnt. �41 , ..
24' 0" MAX. 12' - 0" MIN.
DRIVEWAY R/W LINE
w CONTRACT 1O J JOINT OPTIONAL
SIDEWALK
� LOCATION
SIDEWALK � — EXPANSION JOINT
EX PANSI0F1 JOINT
URB JOINT —
A
S' 0" 6' -0" MIN. 12' -0" MAX. 6' 0" MIN. 12' - 0" MAX.
DACE OF C1iRU
SIDEWALK ADJACENT TO SIDEWALK AWAY FROM CURS
PLAN
r-1 1/2" EXPOSURE
USE EXISTING EXPANSION
JOINT OR SAWCUT AND
PLAT.
ELEVATION B—B SEECDW(�ONO. CSJOI-306,
STREET r. .-^ ' !Afcl�
6 7 \
-OMiMICTED SUBGRADE� 2" OF 3/4" MINUS
SECT10 A—A f
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NOTES
I. CONCRETE SHALL HAVE A MINIMUM BREAKING STRENGTH OF 3000 PS I.
AFTER 28 DAYS , 6 SACK MIX.
2 CURB JOINT SHALL BE A TROWELED JOINT WITH A MINIMUM 1/2" RADIUS
ALONG BACK OF CURD.
3. EXPANSION JOINTS SHALL BE 1/2" PRE.MOLDED ASPHALT IMPREGNATED
MATERIAL OR EQUAL , EXTENDING FROM SUBGRADE TO FINI.4HED GRADE .
A, SEE DWO. NO. CS-300 AND NO. CS-305.
WWASHINGTON COUNTY
0 ,zDEPARTMENT OF I-AND USERESIDENTIAL DRIVE WAY
AND TRANSPORTATION
DATE CIVIL EN91IINICER DRAWN A PWA NO. WASK COUNTY NO.
.L2 o ACA b AS NONE DW— 200
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