12865 SW MAIN STREET EIF,E t
MAIN. - 12865 STR. OFA. PERMIT
CITY OF TIGARC)
REQUISITION
TIGARC, OREGON NO. 91 5 Q
THIS IS �'�)T A PURCHASE ORDER
PLEASE ORDER THE FOLLC,WING: P.O. -
SUGGESTED SUPPLIER
DATE.
- ----- -- ------ —--
DELIVERY TO DEPT
STREET
i.DDRESS
CITY d ZIP CODE
DATE NEEDED
ACCOUNT NO. QUANTITY DESCRIPTION UNIT PRICE AMOUNT
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SPECIAL INSTRUCTIONS TOTAL AMOUIvf
SIGNATURE
APPROVED ^----� — D[PT.NEAo__—___
APPROVED -- CITY WCONDER - - --
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City of Tigard
INSPECTION REQUEST
for
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INSPECTION TIME. /+ A. ��
PERMIT NO. :
CAT E: A DATE ISSUED : Z Z
OWNERS NAME : ---
ADDRESS;
CONTRACTOR : —
TEST :
ONTRACTOR : _TEST : Air p, Wotsr C , Visual Laboratory p
RESULT : Approved �, Disapproved ❑ Pending p
SKETCH;:
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INSPECTOR DATE
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CITY OF TIGARD
Date — - �� Amount DE�-_�=
dollars
Name Cash
M.O.
Address Check X
Bldg. St,Opng. L] Bus Lic. —
Plbg. Pubctns. Bike lic
Elctl. n Copies Sew.Serv.
Sewer ❑ Filing Fine&F. I�
Assmt. Other Zoning C�
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Permit # _ / 7 S
CITY OF TIGARD
11 4 0
APPLICATION - STREET IMPR EMENT/EXCAVATION COPY TO:
ORDINANCE NO, 7414 C] I - FILE
[3 ISC] -INSP.
(INSTRUCTICN3 ON SEPARATE SHEET) E] (YE K) -A -OTHER AGENCY
E] (PINK) -APPLICANT
APPROVED APPLICATION N
NOT APPROVED ❑ CITY OF TIGARD, OREGON FFL AMT.: f
PENDING FEE.PMT. ❑ CITY HALL, RECE TNO.: --
PENDING SECURITY ❑ PUBLIC WORKSDEPARTMENT BY _^_".� — DATE— 7.!V
PENDIN, ACI'NCY "OK" ❑ Application and Progress Record
MAINTENANCE BOND *v--_�--
PENDING IN.'')RMATION ❑ FOR STREET IMPROVEMFNT/EXCAVATIOr4 A5 REQUIRED 41,
ANNUAL 7
PENDING VARIANCE ❑ EXPIRATION DATE:
PERMIT N DATE ISSUED: �_J��J BY: - - y�------_—
(1) APPLICATION IS HEI. :BY MADE TO EXCAVATE FOR AND INSTALL
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
— — 1— v �✓ )tl err a �- -=i
APPLICANT 1009 +'AIfi E42��7'C � �'�•!- -� ` '��
ADDRESS ----CITY---------- PHONE
CONTRACTOR 'i __
A // ADDRESS CITY _ PHONE
PLANS BY C' S sMda _
NAMEDRESB — _IT Y -- -- -_-- -.PHONE-- -
ESTIMATED IMPROVEMENT TOTAL VALIDATION ( COST): E �____ —
DOLLARS
(2) EXCAVATION DATA:
FOR OF FIC USE XM IN
o.oz X >r
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
} TYPE LENGTH WIDTH DEPTH ITEMQUANTI//TY
STREET
L OPENED
` INSPEC- - ---
r��r a �Lr111lLP R TION
E;Q
ESTIMATED STREET OPENING DATE: � ! ! / _ g
ESTIMATED STREET CLOSING DATE: — . _ E
-- _ D _
—STREET
(3) SECURITY NO. W"SECURITY AMT.: $ GG. _ CLOSED
SURETY CO.: _ _ FINAL t — �•� 4 c1
CERTIFIED NFCK _ CAtIH D ON It INSPE:C.
(4) PLOT PLAN: INDICATE SITE PERTINENT pI-4YSICAL SPECIAL NROV ISIONS/CONDITIONS:
FEATURES; EXCAVATION LOCATION Ar* EXTENT.
9
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URB -
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(5) NOTF_: THE CITY OF TIGARD DOES NUT, HEREBY, GRANT PEhMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT-OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE 01' 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 -'O SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS
APPLICANTS SIGN PURE: � �i' �! x •�� DATE
- ... 'fit •yPF��'
APPLICATION — STREET'IMPRC MENT/EXCAVATION COPY TO:
ORDINA, 'E NO. 74-14 Cl (BLIT)) - FILE
❑ (BLUE) -INSP,
(INSTRUCTIONS ON SEPARATE SHEET( L] (FELLOW) -OTHER AGENCY
❑ (PINK) -APPLICANT
—ROVED [] APPLICATION NO.:
T APPROVED ❑ CITY OF TIGARD, ORLGON FEE AMT.: s
PENDING FEE. PMT. ❑ CITY HALL RECEIPT NO.:
PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT BYDATE_. _----
.�.____��_._
PENDING AGENCY ''OK" ❑ Application and Progress Record —
MAINTENANCE BOND
PENDING INFORMATION F.7 FOR STREET IMPROVEMENT/EXCAVATION As REQIJIRF-D u
ANNUAL
PENDING VARIANCE ❑ EXPI RATION DATE:
PERMIT NO.: --- DATE ISSUED: _..L_-1_ --_-__ , BY:
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL -_
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT - —___—
_-.N/.HIE _ -.-- _ADDRESS_____._-__.
CONTRACTOR -_-- -
- - ----- -
NAME ADDRESS _- CTf V_ _-PHONE
PLANS BY _
NAME ADDRESS CITY PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $
DOLLARS
-- - - POP OFFICE USE: UMIN.—
(2) EXCAVATION DATA: _ 0.o:1 x s
STREET DESCRIPTION _ PRZ;GRED & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM � QUANTITY
STREET -
- — _— — OPENED
INSPE - — -- --
R TION
Q
ESTIMATED STREET OPENING DATE: —__L / E
_ S
ESTIMATED STREET CLOSING DATE: / / T
E
(3) SECURITY NO. ----- SECURITY AMT.: $ STREET_ CLOSED
SURETY CO.: FINAL
_ CERTIFIED CHECK ❑ CASH ❑ BOND INSPEC.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS /CONDITIONS:
FEATURES: EXCAVATION LOCATION AND EXTENT.
URB
(5) NOTI_ THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
LIGHT OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE S'TAT'E OF OREGON,
THE APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURITIES, TO COMPLY WITH ALL. PERTINENT LAWS AND
'ONSTRUCTION SPEC FICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY AND
E MPL(,YEES AGAINS' ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
API`LICANTS SIGNATURE _ DATE