14175 SW 112TH AVENUE-1 FILE NO. --�✓
112TH AVE. - 14175 STR. OPN. PERMIT
APPLICATION STREET IMPRC MENT/EXCAVATION COPY TO:
ORDINAIvCE NO. 74-14 1.1 (WHITE-- FILE
(9LUE)--NSP.
(INSTRULTIONS ON SEPARATE SHEET) C] (FELLOW) -OTHER AGLNCY
(PINK)-,4PPLICANT
APPROVED APPLICATION NO.: _40
NOT APPROVED ❑ I CITY OF TIGARD, OREGON FEC AMT.: :
PENDING FEE. PMT. ❑ CITY HALL RECEIPT NO.
PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT BY Al( -- DATE_Z—_j / / 7a
PENDING AGENCY "OK" ❑ Application and Progress Record — — — — —
MAINTENANCE BOND ik ;
PENDING INFORMA-ION ❑ FOR STREET IMPROVEMENT/EXCAVAT ION AS REOUIREO
ANNUAL
PENDING VARIANC ❑ EXPIRATION DATE:
PERMIT NO. 111-_?.a -------. DATE ISSUED: BY;
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
AS DE,SQRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICAP�T , + Ir /r Gk''9 h� !J --�I(OJ s� C�/P/Q�SS `��
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CITU PHONE
CONTRACTCR O pU &IJ, T 334 ��-�CITY PNO��� PH0 NE
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ADDR �/ _._________. _.
PLANS BY . �'f} (
NAME — ADDRE55—�-- --- -- CITY �� PNONE
ESTIMATED IMPROVEMENT TCTAL VALUATION ( COST): $ (9 47
DOLLARS -_
(2) EXCAVATION DATA: FOR OFFICE USE:
0.02x5 = S
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED
TYPE LENGTH WIDTH DEPTH ITEM AI QUANTITY ITEM DATE REMARKS/TYPE BY
STREET
OPEN
ED
IR
SPEC-
EF TION
QUESTIMATED STREET OPENING nATE:-.� [ 7 E
S
ESTIMATED STREET CLOSING DATE: _ I�1� 7 ED(3) SECURITY NO. _ __� � SECURITY AMT.: $ L SED
SURETY CO.:
�_. FINAL
CENTIFIEO CHFCK CASH U 90Nr.•� INSPEC. '
(4) PLOT PLAN: INDICATE SITE PER rINENT PHYSICAL ;PECiAL PROVISIONS J CONDITIONS:
FEATURES, EXCAVATION LOCATION PND EXTENT.
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I5 NOTE THE CITY OF TIGARD DOES NOT, HEREBY GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT-OF-WAY JURISDICTION IS THAW0—F—WA j1 GTON COU�T?_)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 AN INJURY 0141 DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
APPLICANTS SIGNATURE .'7
DATE
1' , w.f!•�'SM J�� �<:_�a:`;,[:S` i i'^, �' •`'i'"si„ 'M.�, :K: .� i'p'r..r 4�'R��'���`y;. _ _ - ,
APPLICATIOry -- STREET IMPRr 'cMENT/EXCAVATION COPY TO:
❑ (WHITEI- FILE
ORDIN, .CE NO. 74-14 ❑ (BLUE) -INSP.
❑ (YELLOW) -OTHER AGENCY
(INSTRUCTIONS ON SEPARATE SHEET) ❑ (PINK) APPLICANT
APPROVED ❑ APPLICATION NO.:
NOT APPROVED 0 CITY OF TIGARD, OREGON FEE AMT.: f__--- -_-.__—
PENDING FEE. PMT. ❑ GITY HALM. RECEIPT NO. --._--._..---.-PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT BY_ -_-__ DATE= -._T-L Y L.__
PENDING AGEI CY "OK" ❑ Application and Progress Record
MAINTENANCE BOND
PENDING INFORMATION INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS REQUIRED
ANNUAL
PENDING VARIANCE EXPIRATION DATE: . _.___-
PERMIT NO. _ -_ DATE ISSUED: BY: _.. ------ - - - - _-
(1 ) APPLICATION IS HEREBY MADE TO EXCAVATI_ FOR AND INSTALL --_-
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT --
NAME — ADDRESS --------�- CITY PHONE
CONTRACTOR —
NAME ADDRESS CITY PHONE
PLANS BY -
NAME ADDRESS -----CITY —HONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $
DOLLARS
---- ---_--- --� --�— -FOR OFFICE USE: MIN.-_--
(2) EXCAVATION DATA: _ 0.02. X s = S__
STREET _ DESCRIPTION PROGRESS & INSPECTION STATUS_
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM A QUANTITY Y —_
`-- — -- - STREET
P N D
-- —__ — -- INSPE -
R TION
Q
E
ESTIMATED STREET<JPENING DATE: T ------ ---
ESTIMATED STPEET CLOSING DATE: _- / - E
(3) SECURITY NO. _T_� SECURITY AMT.: $ CLOSED _ � Ikgf
SURETY CO.: _ FINAL
CERTIFIED CHECK Tl CASH D SON, '- INSPEC. —
----.`_' - - s--
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS /CONDITIONS.
FEATURES: EXCAVATION LOCATION AND EXTENT.
I 1 1 1 —
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'URB - ' STAI
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(5) NOTE THE CITY SOF 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 ANO
EMPLOYEES AG 4INST ANY INJURY OR LLAMJkGE' WHICH MA\ RESULT FROM APPLICANTS ACTIONS.
APPLICANTS SIGNS TURF. DATE L
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