14252 14256 SW FANNO CREEK LOOP FILE NO. 30D-,fp
STR. OPN. PERMU_
FANNO CREEK. LOOP - 14252/14256 t
I
CIT"GEWARD
EXPENDITURE RELVBURSEMENT RE�EST
This !r -1n is a multi-use form. Where appropriate receipts Faust be attached.
Documentation is important for all purposes. Staple documentation to form.
VENDOR NO: vATE 'Ib , ��j8el
PAYABLE T0: `�_ 9 �ucr d �.� v ,v%c L,r, Requested by:
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MISCELI.ANEOUS (parking, books, subscrintiovs, dues, memberships, etc.):
Date Description �_ Account No. Amount
'Jv 3X-Sb
0011 ,
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GENERAL MEAI. EXFENSE:
-Date Descti tion �____� Amnvt,:
Account Number to be charged: R _ Total
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MILEAGE:
Date Description: (Include end/start readings and total miles) Amount
Account Number: Total_ _ miles x$.21 _
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APPROPRIATION BALANCE: AS OF: Signature
APPROVALS (if $25.00 or under may be reimbursed through petty cash) :
(up to $500.00)Section V Hager _ _ Purch. Ay1•nt
($500.01-$5,000.00)Dept. Ilead/Purch. Agent _____—
INSPECTION NOTICE
N /-k-erri I
City of Tigard Department
P.O. Box 23397 i
Tigard, Oregon 97223
Phone: 639-4175
Type of Inspection ✓ C_ L.� ---` �
Date Requested_ cmc Time�__ A.M.
Address / L�r 56n l r_, /JS )6-I 1) Permit #�
Owner r ' �`f— Lot —
j ? yam
Builder
The following Building Code deficiencies are required to be corrected:
Olt - --– - — --
Presented to-- 1 �' _ _ [�p►oved
Inspector - �}���_Q��� J L1 Disapproved
Date
CALL FOR REINSPECTION
0 YES
APPLICATION - STREET IMPRF -MENT/EXCAVATION COPY TO:
ORDINr,,•CE NO. 74-14 (WHITE)•FILE
(YELLOW)-INSP.
(INSTRUCTIONS ON SEPARATE SHEET) (PINK)-O-'HER AGENCY
' p (BLUE)-APPLICANT
APPROVED IK :3-76
7
NOT APPROVED '❑ CI I�' 01• FIGARD, ORIIGON APPLICATION NO.: , -
FEE AMT. S - 2_
PENDING FEE PMT. ❑ CI I N' IIALI,
_�RECEIPT NQ.:
PENDING AGENCY "OK„ OO
PENDING SECURITY ❑ PUBLIC WORKSDEPARTMENi- c7 �
DATE a.]• / 611
❑ BY —C�1pplication and Progress Record — — — — — — — — — — — — — — — —
PENDING INFORMATION p FOR STREET IMPROVEMENT/FXCAVATION MAINT HNAQNIREBOND ax _
13
PENDING VARIANCE ❑ ANNUAL
EXPIPATION DATE:
PERMIT NO. r7 UC�'
1 �T— r -
-- --- . ATE ISSUED: __ L BY: -
(1) APP/LICATIO �S HER BY-MADE TO EXCAVATE FOR AND INSTALL _� NL'.Cd �c. `
- - - -
�� f AS DESCRIBED HEREIN, IN FULL ACCORDANCE WIT/ CITY REQUIREMENTS.
APPLICANT 'w W'0M PSV,. ( N C.
AM 2Q$qG 7J
DDR[
CONTRACTOR a/l /"!� Q SLC (,- 0 V4'v1 aKk- Z-46-3995 C1* �------- �cNr---
AMUE
PLANS BY -- ---- - - -- CIT -- ----piio�i�--
—Tn'HON[
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): : r�OCC�420- CIT
- ---- -- ----- �_-- -�• DOLLAR[
(2) EXCAVATION DATA: pICKUSE -- y;l.IN.
0.04 X f s ,QLCV 'f
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED
TYPE LENGTH WIDTH DEPTH ITEM (! Q ANTITY 11 SM DATE REMARKS/TYPE BY
INS
R 1'10
ESTIMATED STREET OPENING DATE: �C LE
ESTIMATED STREET CLOSING DATE: y 10 T
E
nl
(3) SECURITY NO. -_ SECURITYAMT.: sa .Lti�U "1" as STREET
SURETY CO. CLOSE
- FINAL
CERTIFIEDON _
CHECK ' — CAlH iD r INSPEC.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL
FEATURES; EXCAVATION LOCATION AND EXTENT. SPECIAL PROVISIONS/CONDITIONS:
�
f —T
(UPS
S-1• -0�o1�z7 A 4p r ri' xt t-
- ,,Ile -. •- - - - - -- / �,
I 1
lu
7 � �..— I I r 7i' L -•fit. � `� - 'I
I I '
(5) NOTE THE CITY OF TIGARD DOEq NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT-OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON.
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
1,
GATE
CITY OF TIGARD - RECEIPT OF PAYMENT REC NO: 00100879
NAME: FERNWOOD DEVELOPMENT CHECK AMOUNT : 7.120. 00
ADDRESS: 81 ''0 SW MAPLELEAF ST CASH AMOUNT : . 00
T.TBARD, OR 97223 PAYMENT DATE : 0,?--2a-8u
BLOCK NO/ADDR:
STREET OPENING PERMIT
PURPOSE OF F-AYMENT AMOUNT PAID PLJ'RPCj8E OF PAYMENT
AMOUNT F-`AID
CUSTOMER, DEPOSITS
3, 000- 00 PUBLIC IMPROVEMENT PERMITS 1,20. 00
PHIS IS A REFUNDABLE DEPOSIT
THAW',' YOU
TOTAL AMOUNT PAID
120. 00
REMITTANCE AD\'I 24 .1
11 439
FERNWOOD DEVELOPMENT, INC. I- L) 12 0
tr 44
30182 S W.LADD HILL ROAD 626-5938
SHERWOOD,OREGON 97140 2048
PAY J
��*
PtQ Aj >-t 1—
DOLLARS
TO THE ORDER or DATE
CHECK No. Li CHECK AMOUNT
FIRST INTERSTATE BANK of Oregon.N A
TIGARD BRANCH TIGARD,OREGON
1180020tialle 1: 123000 & 231:419 001224 P
life