13705 SW 118TH COURT FILE NO. ir3Q -�..5'
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DATE ���.-/�_ 8,3 REQUESTED BY L • �• UNIT/DEPT.
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RCHASE REQUEST CHECK REQUEST
EPARE PURCHASE ORDER , CHECK TO BE MAILED WITH ATTACHMENTS
ND CONFIRMING P.O. NOTIFY REQUESTER WHEN CHECK IS READY
ECIAL INSTRUCTIONS iIl ''K NhEI)I:U BY
FACCOlNT NUMBER QUANTITY INVOICENO. & DESCRIPTION TOTAL PRICE
`T'OT'AL REQUESTED �SOtJ
APPROPRIATION BALANCE $
Amount / Init ial
APPROVAL'
SECTION MANAGER (Less than $1(m)
DEPARTMENT HEAD
('ITY A[�MINISTRATUR'S APPROVAL
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APPLICATION -- S-fREET IMPRt '.MENT/EXCAVATION COPY TO:
❑ IWHITE)• FILE
ORDIN,,,.CE NO. 74-'4 ❑ (BLUE)-INSP.
❑ (YELLOWI-OTHER AGENCY
(INSTRUCTIONS ON SEPARATE SHEET) ❑ )PINK)•APPLICANT
APPROVED [j APPLICATION NO.: / iv-z
CITY OF TIGARD, OREGON tia1D,
NOT APPROVED ❑ FEE AMT.: E
PENDING FEE. PMT. ❑ CITY HAil. RECEIPT NO,.: ZC24 '?
PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT BY DATE_ J3Z /9-5
— — — — — — — — — — — — — —
PENDING AGENCY "OK" ❑ Application and Progress Record MAINTENANCE BOND M
PENDING INFORMATION ❑ FOR STREET IMPROVE"1ENT/EXCAVATION AS REQUIRED o
ANNUAL U
PENDING VARIANCE ❑ EXPIRATION DATE: __�---
PERMIT NO.: 1,5q - Y 4 DATE ISSUED: ._ _QZ 5 .i _ , BY: ..�,c__1
(1 ) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT �c !'!y k� _% 'rl�' S k% / C TCfa g,10( �D•-3'1�--11-��
NAME ADDRESS C 1 TIT PHONE
CONTRACTOR _ —
NAME ADDREfi PHONE
PLANS BY____ —
NAME ADDRESS CITY�-- PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ -
UOLLARf
(2) EXCAVATION DATA -- FOR OFFICE USE — 0MIN.
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM 4 QUANTITY
0 STREET
INSP
R TION
--- g —
Q
E
ESTIMATED STREET OPENING DATE'_. / L_, __-__ S
T --
ESTIMATED STREET CLOSING DATE: / _1 E
D
STREET
(3) SECURITY NO. _-____ SECURITY AMT: S __`1-s!�_� CLOSE J r
SURETY CO.: FINAL
—� _ _ — — P S-�U- a
CERTIFIED CHECK 9' CASH O BOND U ._
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS:
`
FEATURES; EXCAVATION LOCATION AND EXTENT. /�+�•F' lC- 'rs/,l C //L�'S���/�
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(S) NOTE THE CITY OF TIGARD DOEL4 NOT, HEFF.SY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT•C'F-WAY JURISDICTION IS THAT OF WAISHINGTON COUNTY OR THE STATE OF OREGON.
THE APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURITIES, TO COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PCRTINEN* TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMA GE WHICH MAY RESULT FROM APPLICANTS ACTIONS
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APPLICANTS SIGNATURE DATE /
CITY OF TIGARD- 12420 S.,6..MAIN—TIGARD,OREGON 97223
RECEIPT ,oma
AMOUNT:
._JOLT ` 75
NAME: CASH:
ADDRESS!—
ADURESti _A—z'
to O 44,y CCHECD
__ - - - - -- M.O: - --
* OF
FOR: ACCT. # PERMITS SURCHARGE AMOUNT
SEWER BILLINGS 40-364 S ---
BUSINESS LICENSE 05-331 _—
PLUMBING PERMIT 05-332
MECHANICAL PERMIT 05-332
BUILDING PERMIT 05-333
SEWER CONNECTION 40-363 ---
SEWER INSPECTION 40-365
SYSTEM DEV,CHARGE 25-366 -
PARK DEV.CHARGE #1 30-367
PARK DEV.CHARGE *2 30-368 _--
ZONING ADJUSTMENTS 05-362 a-•�st�--
/ TOTALS
RECEIVED BY-
PERMIT NUMBERS ASSIGNED:
Number Amount Number AmbuM Number Amount
RECEIPT
12 6 5 7