11020 SW 115TH AVENUE FILR NO. 'qO
115T6 AVENUE - 11020 S7R. OPN PERMIT
i
QTY OF `I'IGARL)
EYPtNDT1�JRE RkQUI',,;r
Ihi..s form is a multi-use form. Appropriate receipts must be attached. Documentation
is important for all purposes. Staple documentation to form.
VENDOR NO.: ` -- DATE:
PAYABLE- Zn: _�✓�vi;e` �, Cov . PErAJrTfD BY:
14 5,6 . �U-- v_e_ 3Z*_
2Z"— * Approved request due Wednesday
10:00 AM to A/P for checks by
Friday.
KIS(aELIANBDW EXPENDrTURES:
Dace Description, Invoice No., e+c. Account No. Awount
10 --ZZOOU
10
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`1D- Zd-74BS
Mileage $0.255 - -
APPROPRIATION BALANCE: _ AS OF: S,-GNARM:
(U) to $25.00) Section Manager _ _ Furch. Agent
($25.01-2,500.00) Division Manager
($2,500.0.1-7,50C.00) Dept. Head —�—
($1,500.01-15,000.00) City Administrator
($15,000.01- ?) Local Contract Review Board -
ke/1501F
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APPLICATION - STREET IMPRO'11 HENT/EXCAVATION COPY TO:
OR DINANO. 74-14 ❑ (WHITE)-FILE
❑ (YELLOW)•)NSP.
(INSTRUCTIONS ON SEPARATE SHEET) ❑ (PINK)-OTHER AGENCY
9
(BLUE)-APPLICA
APPROVED ' APPLICATION NO.;
NOT APPROVED `1 CITY OF TIGARD, OREGON FEE AMT.: E � 0,
PENDING FEE PMT. ❑ CITY HALE. RECEIPT NO. " /IQJl— W-74 �
PENDING SECURITY ❑ PUBLIC WORKS OEPARTMENT RY Km DATE IZ / 7L_`77)
PENDING AGENCY "OK" ❑ Application and Progress Record w —MAINTENANCE BOND r
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS REQuiRED —
ANNUAL.
PENDING VARIANCE ❑ EXPIRATION DATE.
PERMIT NO DATE ISSUED: }12 / 7- BY: _ ,Le- —
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL_
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT _t�k L/ c�7Ci1` 1�Y34, S6 `f4l 3.��__P4r � 7SC� dr38
NAME ADORES!' IT PHO IF
CONTRACTOR L t.,_� C� C cx�� _ I143(fi S� �o�� 344 V"A\"A ___ -7�(0 -D3y
NAME _ - ADDRESS CITY - PHONE
PLANS
HONYEPLANS BY _
NAA7E - ADDRESS ¢ CIT PHONE
ESTIMATED l�'.PROVEMENT TOTAL VALUATION ( COST): $ ____��U ��`
DOLLARS
(z) EXCAVATION DATA: FOR OFFICE sf: MIN
_ 0.04 X f_ = f • 7
STREET r DESCRIPTIO! PROGRESS & INSPECTION S 1 ATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
_ TYPE LENGTH WIDTH DEPTH ITEM & QUANTITY
W STREET
Wel P N LPti 1
IVSFEC- -
R TION
E
r�
E
ESTIMATED STREET OPENING DATE: �� Q � S
�2 --
ESTIMATED STREET CLOSING DATE: , QT g
D r _
STREET
(3) SECURITY NO. _- SECURITY AMT: S_ ._''- CLOSED
SURETY CO.: - NSFE
POND C. !J ('' li,?
___ cer+ririrDcrcecK
(4) PLOT PLAN: INDICATE SITE pj4T PHYSICAL SPECIAL PROVISIONS/CONDITIONS
FEATURES; EXCAVAT LOCATION ANL T. �• •_�1102-0 - r Gt/ //moi
( I !y 1
eq
— — fit.
l I ,
4,100 Ill S/I�G 0L�_
I � I
(5) NC 7E THE CITY OF 7 GARD DOES NO . HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT-OF WAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE GF OREGON.
THE APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURITIES, 'O COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT Or THE WORK, AND TO SAVF HARMLESS THE CITY ANb
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT F►`OM APPLICANTS ACTIONS
APPLICANTS SIGNATURE DATE 4") �C _
Ot" r-lAYMEMI RECFif-r NO.
CHECk (AMOUNT ; Itis
DANIEL G. coov. corv,:,T#% c,o. CASH AMOUN'�
tESS 11-4136 S'E 9(.)TVI AVE. Nn- ; 72-1, PAYMENT VATE 90
r ORTIAND, Of-;' 7 4,4, G(ADD I V I SR)I CIN
F"URPOSE OF PAYMENT F'Al L, or* rAYMENT AMOUN1 PA I D
U':.bTOMER DEF*0 -,'5c3. ,-,(, PUBLIC IMPPOV
II
` I'; I 'M I T NO. :7.98 -9t,)
I i,,L AMOUNT PA
DANIEI. G. COOK CONSTRUCTION Co.
11436 SE 907H AVF N0. 324 78d-2138
PORTIANO, OR 97266 / 3L 9 r ti
C r r r
PAY r0 rHf - !9_-�_ 4.121101,
ORDER or !• , 4 f 1230
1Rnf Infersfale 9enk7�
First _- DOLLARS
of Oregon,N.A,
trtterstate PO RON 44a1 ranch
WUsonviUe.Orcg"81070 `
230001231:0
87 003236
'-' K' 0 ue 3 29
0 11570 /� 11530\00 / \\ah• "- -��'�" .t--f-v r
��ro 1a \\h60 14s \\
gp
66n \ sesi� QPM O -
/ 69� SO h 06, �a� J in -- -
��� < si • ai 11380 11375 I c
11275
3p X1370 11365
r• 's 9015 1rAr,n It2a`' 1J \�ti
=
11355 1a 11195 I 1117-5
1737 076T 350 ,u
Z. 0� O 113 45_
m 1080 � 1235 11205 0Q 11165
10824 J 11 3
_
344
10046 ss a 1 to 1 WN �.I0840 tMn ��3is 3
!0870 11342
> 10860 – •�, `i – / ,145
tai - cp Nps
wcv
a p N O N O
;p109nr `qtr 1►, rn M M N a'
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10908 to cD \6q o o 0 0 0� o W 11125
to lD ti W O
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N W. EISN,G��� J I/S.w ��, �.fr T O W OD
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p' to to u� to to w v> to to //OJ
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inN I m M o to v 11505 11020 1gIS0
a ~ ~_ to ra so to to tr, 0 4 5 :} 1'VO
I
i j._ � MAN7ANITA Tr 11060
�S W 1–r – c IIC85 I 1
?'� O o I 1 C O O
oN t o a Q. o o o 'n a
to c W to to h _ 11150 11115
t a 11155 II M45
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M ! 11180
V, /
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/TI OTHj PI' i I
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11200 '^ / tin cNv
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to
/ C� en N •�) e.J
W/ .moi w m
M O � Oo_ o Iko rn �0 111510 I __
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11500 i
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'Inn
to CY 11492
11487
41
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