12755 SW 128TH AVENUE *; 4
i
�w
•.A
a
4 •
SII n.
r
t
h
l
p �
R'
APPLICATION — STREET IMPR 7-MENT/EXCAVATION Cc PY TO:
:�+HITEI'FI_
ORDIN,,ANCE NO. 74-14 0_UE! INS✓.
IV
_
INSTRUCTIONS GN SEPARA?E SHEET
�IPINKI -AA -OTMEH ave' r_v
PP LIC AIV'f
APPROVEDX. APPLICATION NO.: _ Z7 ---
I'I''%T APPROVED I] C.II-Y OF TIGARD,OREGON FEE AMT.: S_ ..•_�"'
PENDING FEE. PMT'. ❑ CITY HALL. R5CEIPT NO.:
PENDINGSEk.:URITY FJPUBLIC WORKS DEPANTMENT BY _� DATE 7L
PENDING AGENCY "OK"
G Application--nd 1'rogi'ess Record
MAINTENANCE BOIJD M�S►.�SdQ.-L
PENDING INFORMATION ❑ I-OR STREET IIJI0'"CIVEMENT/EXCAVATION AS REOUIREJ
INNUAL.
PENDING VARIANCE ❑ EXPIRATION DATE:
PERMIT NO. - DATE ISSUED: !_ 7� BY
------_.
(1) A%PPLICATION IS HEREBY MADE: TO EXCAVATE FOR AND INSTALL
AS DEa(' RIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT _
NlMEAUDRESSC7T-V--- _ - PHONE
CONTRACTOR _ _
NAMr A06-04 - 'Cl 7Y PHONE
PLANE' BY
NAME ADpR[SR � CITV - - NON!
ESTIMATED IMPROVEMENT TOTAL VALUokTIGN ( COST):
DO!_I.ARS_ _
OR OFFICE Y.011!1 _ GQ ❑MIN.
(2) EXCAVATION DATA: F
0.02-X S ;a: .R s
STREET �— _DESCRIPTION PROGRESS & INSPECTION S i ATUS
NAME SURFACE CUT CUT CUT MIITERIAL I"aTALLED ITEM DATEREMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH — ITEM Q QUANTITY ���
L_ .4 4. STgREETD
ION
E —_
ESTIMATED STREET OPENING [)ATE: / S
ESTIMATED STREET CLOPING DATE: I I ._ E -
- D --- —
1 / , . STREET
(3) SECURITY NO.�I :.`1 5KCUR1TY A EMT.: S��_ . CLOSE
SURETY CO.: IJ{ r e��\ �� 1� Ie r I'1L .L�F._ FINAL
CERTIFIrOCHECK ❑ CASH ❑ BOND 11 INSPEC. _
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTENT. _ —!
c
� 2� I I _ ya ::z►rL� -�r
1
(5) NOTE THE CITY OF TIGARD DOES NOl', HEREBY,. GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
FIGHT OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON.
THE APPLIC.JNT 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 I
h7-
A
MEMBER OF uNITEO PACIFIC INSun ANCE GROUP
I� HOME OFFICE: TACOMA, WASHINGTON
• °
LICENSE OR PERMIT BOND Bond U 97 $? 29
KNOW ALL MEN BY THESE PRESENTS:
•
That we, fillLER-_$_,S_0S__CQN1M.GLQAS- INC-- •
as Principal, and UNITED PACIFIC INSURANCE COMPANY, a corporation organized under the laws of the State
• •
• of Washington huvina its principal office in the city of Tacoma,Woshington, and authorized to transact the busi• •
ness of Surety in the State of Oregon _ __,as Surety,are held and firmly bound unto - -
•
•
• C I T Y QE-TAARD,_ORE.COQ,_____ os Obligee,In penal sum of •
• TWO '!UNURED EIGHTY and no/I00"_ Doilurs, •
lawful money of the United Staten, for which payment, well ural truly to be mode, we bind ourse!ves, our heirs, e
•
e execuiorn, administraturs, successors and assigns,jointly and severally, firmly, by these presents. •
• •
° WHEREAS, the said Principal has applied to said Obligee for a license or permit •
• •
Street Bening. Permit under ordinances 14-1,4 at d -76-I1 •
° NOW, THFRE[ORE, THE CONDITION OF THIS OBLIGATION IS SUCH, 'hat if the said Principal shall in- •
• e
demnify c,,d Obligee abreach against all loss ,u it caused by said Principal's each of any ordinance,rule or regulation
• •
° relating t'•ereto, then the above obligation shall be void,otherwise to be and remain in full force end effect. •
° PROVIDED, THE LIABILITY OF THE SURcTY upon this bond shall be and remain in full force and effect for
•
e •
• ti,efull penod of the certificate, license,or permit issued to the Principal above named but not beyond.__N0vQmbK- •
• I __, 19_—,or ten dnys after receipt bythe Obligee of owrill•n notice signed •
• by such Sure:y,or its authorized agent, stating that the liohility of such Surety is thereby terminated and canceled. •
• Providei further, that nothing herein shall affect any rights or liabilities which shat' have accrued underthis bond •
e prior to he date of such termination. •
• e
• This bond may be extended for a further form by the issuance of a Continuation Certlfll:afe signed by the Surety. •
•
•
• Doted November. 15,_1976 , 19 •
r
•
Ml�1ER 1�� __ r t3N A6TRA�t 1�rv_- _ •
• „�, ,_�,�,0,.3 __ •
�. dA..CMAL •
•
• J �� �.)7t�J UNITED P IF INSU ANCE COMPANY e'
• V 1 f(, _ •
By: rRs.- Hf"1C\ •
ff
9.l sirs_.L,r�m•�,V.rmtt hap-r,•n•rxl f,,.m N+v sfis
• • • • • • • • a • • • • • • • • • • • •
0 0 0 0 e s 0 0 0 0 • 0 •
Q
S r
r z d
ip
LLJ
.. 0 cr
c
a t 0 �
x
w Z N F
0 I C , V -
wU-
CA
_ F--
J cr / O Cl
w 1L
.N
Ir 1-1
cr-
LL,a
V) 0 z oO
a•. itr
z il.
x O � t Q U-
1
1 w Q1 I•. ";L 0
i
o Q A z a,
} , z .i w
41 Q C N
i N cc
o ' w0 w w
(n - w z
i
z cr )e Q
IID — . 0 d
w -
1 L Q q (r fn
'1 i iJ M 0-
3 a O