14245 SW 112TH AVENUE-2 FILE NO. i
112TH AVE. - 14245 STR. OPN. PERMIT
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APPLICATION - STREET IMPR' -MENT/EXCAVATION COPY TO:
LI IWHITE)-FILE
)RDINi,,._E NO. 74 14 [] (BLUEI -INSP.
UCOS ON :SEPSHEET) E] (YELLOW)P OTHER AGENCY
(INSTRTINI 0 (PINK) -APPLICANTAPPROVED 7�_' APPLiCAT1ON NO.: to
NOT APPROVED ❑ CITY OF TIGARD,OREGON F4E AMT.: s • '
PENDING FEE. PMT. ❑ CITY HALL RECEIPT NO.:
PENDING SECURITY ❑ PUBL IC WORKS DEPA R TMEN T aYA+__ 2 DATE 7 LLI/ 7)7
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PENDING AGENCY ''OK" C] Application and Progress Record M 4
MAINTENANCE BOND * � s•
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATIO J AS REQUIRED ❑
ANNUgL O
PENDING VARIANCE ❑ EXPIR
A
TION DATE: _
PERMIT NO.: - 7f _., DATE ISSUED: 7 I��l 24 BY:
(I) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY R QUIRCE,MENTS.
APPLICANT _ iL �� 11�c /J�/O S. 0 6 / _7J2_J
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NAME ADDRESS CITY PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ ___$�►00 _.
_ DOLLARSFOR OrF
(2) EXCAVATION DATA: ITY
ooz x BICE#Qa tSTREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIALINSTALITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM & QUANT
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ESTIMATED STREET OPENING DATE: �Lyc_/_l ET
ESTIMATED STREET CLOSING DATE _��2/ ?alp- ED
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(3) SECURITY NO. ------ SECURITY AMT.: $ _ CLOSE
SURETY CO.: _ FINAL
CERTIFIED CHECK ❑ CASH 0 BOND U INSPEC•
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL - ,T SPECIAL PROVISIONS/CONDITIONS
FEATURES: EXCAVATION LOCATION AND EXTENT.
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(5) NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT-OF-WAY JURISDIC-'ION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON
THE APPLICANT AGREES TO DLPOSIT THE REGU1RED 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 _ , )Z., .<A. DATE
APPLICATION -- STREET IMPRI -MENT/EXCAVATION COPY TO:
ORDINh..CF NO. 14-14 (WHITE)-FILE
,� IRLUE) -)NSP.
(INSTRUCTIONS ON SEPARATE SHEET) ❑ (YELLOWI-OTHER AGENCY
U (PINK) -APPLICANT
APPRO\'ED D APPLICATION NO.: —
NOT APPROVED ❑ CITY OE TIGARD, OREGON FEE AMT.: S
PENDING FEE, PMT. U CITY HALL RECEIPT NO.:
PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT By —_ DATE
PENDING AGENCY ''OK" 0 Application and Progress Rcc•ord — — — —
MAINTENANCE BOND 7k
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS REQUIREn -
ANNUAI. Ll
PENDING VARIANCE. ❑ EXPIRATION DATE: /
PERMIT NO.: DATE ISSUED: ---_--.L_.-1BY:
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
-APPLICANT
-- --— --- ------ — -- -- -
NAME ADDRESS CITY PHON[
CONTRACTOR _
NAME ADDRESS CITY PHONE
PLANS BY _
NAME AODR[S4 .---_— --..T __—.___CITU ON[
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ _—__—
__ _ DOLLARS
-FOR OFFICE US[: "MIN.
0.02
(2) EXCAVATION DATA: o.oz X S
STREET DESCRIPTION _ _ PROGRESS 8c INSPECTION STATUS
NAME SURFACE CUT CUT CUY MATERIAL INSTALLED ITEM DA'Z'E REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM A OUANTITY
STREET
PENED
INSPE -
R TION
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Q —S L �'. L
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ESTIMATED STREET OPENING DATE:._______.—_-_ / / E
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ESTIMATED STREET CLOSING DATE: — / / Alr
ED
(3) SECURITY NO. _ STREET
SF CURITY AMT: $ _ ctosE
SURETY CO.: _ _ FINAL
CE RTI rIEo CH[gK ❑ CASH ❑ MOND INSPEC.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTENT.
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(5) NOTE. THE CITY OF TIGARD DOES NOT, HERESY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT-OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OREG^N.
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 A
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
APPLICANTS SIGNATURE DATE / /
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CITY OFTIGARD
Dale —Zr, 95 amounf
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dollars
Name ---- Cash
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Address U 1 tj Chuck -),f
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Elctl. Copies D Sew.Serv,
Sewer Filing u Fine&F.
Assmi. Other u Zoning
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Permit
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