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APPLICATION STREET IMPROVEMENT/EXCAVATION , — COPY TO:
ORDNANCE NO. 74-14 �, , , J O (WHITE)-FILE
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(INSTRUCTIONS ON SEPARATE SHEETI (PINK)-OTHER AGENCY ► I
(BLUE)-APPLICANT
APPROVED } APPLICATION NO.:
NOT APPROVED ❑ CITY OF TIGARD, OREGC°,d FEr_ AMT.: s
PENDING VEE. PMT. ❑ CITY HALL RECEIPT NO.:
PENDING SECURITY 0 PUBL IC WORKS DEPA R TMEN T by - ' DATE—_--L_..—_/__--.
- - - - - - r - - r
PENDING AGENCY "OK" ❑ Appl: ction and Progress Record
MAINTENANCE BOND M_
PLNDING INFORMATION ❑ FOR STREEI IMPROVEMENT/EXCAVATION AS REQUIRED if -�- --
ANNUAL
PENDING VARIANCE ❑ EXPIRATION DATE:
PERMIT NO.: _.------ - DATE ISSUED By-'_ . BY
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL_
_ AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT t i(j4 4"7
NAME AGGRESS CITU PHONE
CONTRACTOR _
—�---NAME ADORES5.___ CITU
,
PLANS BY
NAME ADDRESS_- CITv_ -FNCNE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S � —
DoILLA.as
(2) EXCAVATION DATA. FOR OFFICE USE nM,N.
0.04 x f
STREET DESCRIPTION PROGRESS he INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL, INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM 1! QUANTITY
--�-� -- STREET '-
-_ PErI TD
—. - INSP r'- ------
R TION
E
O
ESTIMA rED STREET OPENING DAVE:—. S
ESTIMATED STREET CLOSING DF,TE: _r E
D
(3) SECURITY NO. SECURITY AMT. S - STREET
.,�_.- cl.osro
SURETY CO.: FINAL
cF"TIFILD cflecK CASH POND r INSPEC.
(4) PLOT PLAN. 114DICATE SITE PERTINENT PHeSICAL SPECIAL PROVISIONS % CONDITIONS
FEATURES EXCAV/TION LOCATION AND EXTENT.
11 ♦ I I 1 1 __ .yc AL
CURB (. �� _ _ .� ._ _ � .� ♦ _ i�: `c r, Al., .
01
(5) NVTE THE CITY OF TIGARD DOES NOT, HEREBY, GRAFT PERMISSION TO APPLICANTS ,O CONDUCT WORK WHERE
RIGHT OF-WAY JURISDICTION IS THAT OF WASHINGTON t-.OUNTY OR THE STATE OF OREGON.
TNF. APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURITIES, TO COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WrRK, AND 7'0 SAVE HARMLESS THE CITY AND
EMPLOYEE; AGAINST ANY IIIJURY OR DAMAGE WHICH MAY RESULT F ROM APPLICANTS 4C.'IONS.
APPLICANTS SIGNATURE. DATE _.L —