9705 SW FREWING STREET FILE NO.
EREWING ST. - 9705 STR.OPN. PERMIT
APPLICATION — STREET IMPR" CMENT/EXCAVATION COPY TO:
CrZDIN,vaCE NO. 74-14 U (WHITE) -FILE
❑ (BLUE)-INSP.
❑ IYEL.LOW)-OTHER AGENCY
(INSTRUCTIONS ON SEPARATE SHEET)
❑ (PINK)-APPLICANT
APPROVEDAPPLICATION NO �rG►��
NOT APPROVED Li �
CITY OF TIGARD, OREGON FEE AMT.: S .�^
—
PENDING FEE. PMT. ❑ CITY HALL REC IPT NO.: –2•�dJ
PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT BY _�_ DATE /
PENDING AGENCY "OK" ❑ Application and Progress Record
MAINTENANCE BON #/
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION ASREQUIRED
ANNUAL
PENDING VARIANCE
�"� .,❑ EXPIRATION DATE:
PERMIT NO.: !10— DATE ISSUED: 'I /.S/ Z f , BY:
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL uL,4
--- ----_ _ AS DESCRIBED HERZ04, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT �.� '.� .0 ' !✓ ---_
*A ADDRESS CIT '-+HONE
CONTRACTOR_ /Y Slv 16tZ
AME ADDRESS CITY,�- -P14ON'E_-
PLANS BY ___
NAME ADORLSS CITY
ESTIMATED IMPROVEMENT IMPROVEMENT TOTAL VALUATION ( COST): t
DOLLARS
FOR OFFICE USEi _ -- �DMIN
(2) EXCAVATION DATA:
0.02 x= ;U S Ld• S a
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MA"'dRIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM At QUANTITY E
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ESTIMATED 5 GREET OPENING DATE:
ESTIMATED STREET CLOSING DATE: �� / T
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(3) SECURITY NO. —_�—SECURITY AMT.: S_ �_ -' STREET
CLOSE
SURETY CO.: _- � [ +t/j^ __ FINAL
E_RTIFIEO CHECK 1J CASH D BOND d INS PEC _
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTENT.
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CURB
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(5) NOTE. THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CVNDUC f 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 PERTOJENT 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 ACTION.,.
r
APPLICANTS SIGNAtU � ����
DATE � � �
APPLICATION -- STREE f IMPRf MENT/EXCAVATION COPY TO-
ORDINHI„CE NO. 74-14 L 1 !WHITE! - FILE
LJ (BLUE) -INSP.
(INSTRUCTIONS ON SEPARATE SHEET) L) (FELLOW) - N AGF.NCV
[ ] (PINK) APPLLICCAANT
APPROVED Ll APPLICATION NO.:
.JT APPROVED ❑ C]'I Y OI' I IGARD, OREGON FEE AMT. E—. _--
PENDING FEE. PMT. ❑ CITY HALL. RECEIPT NO.: —__—
PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT By DATE______ _ _ _ _ _ _ _
PFND!NG AGENCY "OK” E] Application and Progress Record
MAINTENANCE BOND 1R�.
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS REQUIRED U
ANNUAL
PENDING VARIANCE ❑ EXPIRATION DATE:
('ERMIT NO DATE ISSUED --L--�------- BY: --
(1 ) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT Z awl
NAMEADDRESS-- CITY PHONE
CONTRACTOR
NAME_ AD'-DRESS_ _ _ -CITY PHONE -..._.
PLANS BY —,_,
N AM'E --_ ------- -_--------ADDRESS --- -------- ---- CITY -- -- - - PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): ;
DOLLARS
--- -.-
FOR OFFICE USl: C7MIN.
(2) EXCAVATION DATA:
_ o.oz x s.—__ = i.—
STREET DESCRIPTION ~ PROGRESS_ & INSPECTION STATUS _
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKSJTVPE BY
TYPE LENGTH WIDTH DEPTH_ ITEM & QUANTITY
STREET
_
OPENED
INSPE - 7 �+-
- R TION A+- 4, I+ C r
E
Q
ESTIM,'TED STREET OPENING DATE: E� � _-_ g
ESTIMATED STREET CLOSING DATE: _ T
— E
D
STREET
(3) SECURITY NO.
____ SECURITY SECURITY AMT,: E_ _ CLOSED
SURETY CO.: FINAL
CERTIFIED CHECK IJ CASH U SONO INSPEG.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL - SPECIAL PROVISIONS/CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTENT.
I I I
I ! I I
I I i I I
I I I
(�) 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 OREGON.
THE APPLICANT AGREES TO 'DEPOSIT THE REQUIRED SECURITIES, TO COMPLY WI rH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICAT:ONS 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.
AI'PI..ICANTS SIGNATURE. „� DATE 1
C
CI OF TlGtARl)—12420 S."W.CEIPT r.,IAIN—TIGARD,OREGON 97223
RE
DATE: AMOUNT:
DOLLARS
-ril
C
NAME:
("CHECK'
ADDRESS:
M.O.:
OF SURC•HARGE AMOUNT
ACCT.0 PERMITS `�77 7"&� -j'.."..
.SEWER BILLINGS 40-364
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
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513�5, %_yTOTALS
RECEIVED BY:
PERMIT mumuns ASSIGNED' Number Amount Amount Number— Amou"-f--
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