12205 SW 127TH AVENUE FILE NO. 2-2-�-' -'6-
127th AVE.-- 12205 STR. OPN. PERMIT
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APPLICATION — STREET IMPP 'EMENT/EXCAVATION COPY TO:
OR DI h,,INCE NO. 74-14 Ll ('WHITE)-FILE
❑ (YELLOW)-INSP.
(INSTRUCTIONS ON SEPARATESNI.rT) ❑ (PINK)-OTHER AGENCY
1 ❑ (BLUE)-APPLICANT
APPROVED ( ( .l APPLICATION NO.,
NOT APPROVED ❑ CI FI' OF TIGARD, OREGON FEE AMT. E p/[�I f c) 'Uo
PENDING FEE PMT. ❑ CITN' HALL. RECE PT NO. p p3 U
PENDING SECURITY ❑ PUSLICWORK,SDEPARTMENT BY ti_ DATE /Z //1
PENDING AGENCY "OK" ❑ Application and I'rogress Record
PENDING INFORMATION ❑
FOR STREET IMPROVEMENT/EXCAVATION ►dAIN TEEQUIREDOND
ANNUAL ❑
PENDING VARIANCE `-] EXPIRATION DATE: /
PERMIT NO.: _tea—�'�_�' ? __ DATE ISSUEm l!S�i 8' -- . BY
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL -_ _0\ V-aD.c
_ AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT —
- NAM[ ----- ---_-- AODR[SS CITY PHON[
CONTRACTOR S�tir.r11•K'�SSQI� ►rDF►St.� Cci70 n� fe 60`r0___—_�_�
NAME ADDRESS CITY PHONE
PLANS BY
- NAME ADDRESS ----..._ CITY -PHONE ----
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S 3bc,, QQ
DOLLARS
...♦ -�. -� i_--. FOR OFFICE USE:
(?_) EXCAVATION DATA: 0.04 X s
STREET _ DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM 6 QUANTITY
S"rREET
---
INSPEPEN C-
n
R TION
E -
Q
U
ES•rIMATED STREET OPENING DATE. _� / E
ESTIMATED STREET CLOSING DATE: /— / TE –"
D
(3) SECURITY NO � —
SECURITY AMT,: t___�DSTREET cl_osED
SURETY CO t FINAL
_ CE RTIFIEDCHECK tlCASH Ll _ �owD INSPEC.
(4) PLOT PLAN: IND•-ATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS /CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTBNj.
T
- r --
1 1 1 I r
(5) NOTE THE CITY OF 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 O'IEGON
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 ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS
APPLICANTS SIGNATURE J
DATE
PLEASR TAKE THIS TO THE CASHIER FOR A RECEIPT
NAME: DATE:
ACCT. DESCRIPTION AMOUNT
10-220 Refundable Performauce Bond Deposit t
10-435 Sign Permits HOP TU $
10-436 Public Sewer Plan Check/Inspection Fee t
10-436 Public Storm Plan Check/Inspection Fee $
10-436 Street Dedication/Public Improvement Fees t
10-436 - _ Street Opening Permit
10-437 SubdLvision Applications:
-- S MLP —
10-438 Zoning Applications:
ZC CPA ZOA PD Misc
SCF. CU SLI= y s
10-440 Other Planning Fees:
SDR
Non refundable portion of Appeal Fees s
10-220 Refundable portion of Appeal Fees $
21-442 Street Light Fee s
10-451 Document Sales:
Enrg. Planning Bldg.
10--451 Street and Trat°ic Signs s
10-430 Business Ta.c S
TOTAL, S
104 5P)