9675 SW SERENA WAY FILE NO. I 7J
SERENA 1VAY - 9675 STR. OPN. PERMIT
APPLICATION STREET IMPRf "MENT/EXCAVATION COPY TO:
G (\VHIT[) -FILE
ORDINH,-4CE NO. 74-14 0 (NLUE)-.NSP,
(INSTRUCTIONS ON SEPARATE SHEET) [] (YELLOW)_OTHER AGENCY
[] IPINKI�+-APPLICANT
APPROVED 11 APPLICATION NO.: cx 3 _
NOT AFPROVED ❑ CITY OF TIGARD, OREGON _
FE6 AMT.: :
PENDING FEE.PMT. ❑ CITY HALL. REv! T 0.:.T& G'
PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT By I''�.— DATE r
PENDING AGENCY "OK" Ll kpplicalion and Progress Kc(urd — — — — — — — — — — — — — — — —
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION MAINSERNAP�CE BOND rM
ANNUAL ❑
PENDING VARIANCE ] EXPIRATIONDF•T�E`: ` / _—
PERMIT NO.: —_ J1.j- `s ,� DATE ISSUED; / % / -?� , BY:(1) APPLICATION APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
------ _-- AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REWIREMENTS.
APPLICANT 1-����IC t)c'6C, L L 7 5 cc ,$ E-12E-LA W4 (l4-ARSCQ (�<S`/'- �y7�
NAME ADDRESS C17V PHONE
CONTRACTOR) I c�( 04 ws IL ?c ilC ,l c. I TIt/iI;J1 ('/L 6 L- '/-Z .
ME ADDRESS CITTA-- -PHONE
PLANS BY �- (�J.`IL l>c"I „_ 1 1. ;mot,, 1
AME ADORFSCITvrHON[
c�1_
ESTIMATED IMPROVEMENT TOTAL VALUATION I COST):
DOLLARS
— -----
UL)MIN.
(2) EXCAVATION DATA: FOR OFFIC:[ SE.0.o-'X s • s ___—�
STREET DESCRIPTION PROGRESS & INSPECTION STATUS__
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED
TITEM DATE REMA7KS/TYPE BY
'TYPE LENGTh WIDTH DEPTH_ ITEM d QUANTITY
STREET
-- — Ilt
Ih9P C
R TION
,Q
— u
/ /
ESTIMATE ) STREET OPENING [)ATE:_— E g
ESTIMATED STREET CLOSING DATE: T
�.._._ E
STREET
(3) SEC-URI-TY NO. _- - -- E6{�RE -Y-AMT; S �__ ___ CLOSED
SNRETY GO.: .— _-__ FINAL
ClIflIfTIFIROCHECK U CASNSO'NO� n INSPEC.•
(4) PLOT PLAN: INDICATE SITE PERTINENT PI"'J,ICAL SPErIAL PROVISIONS/CONUITIONS:
FEATURES; EXCAVATION LOCATION AND LXTENT.
t t --
CURB
It
Att
-17 1 1 ANI
(5)
1 I Ir
(5) NOTE. THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCE WORK WHERE
RIGHT OFWAYJURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON.
THE APPLICANT AGICEES TO DEPOSIT THE REQUIRED SECURITI[S, TO COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK. AND TO SAVE HARMLESS THE CAT- AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS
1
APPLICANTSSIGNATU4E )' _—__ DATE. / 0
/
CITY OF TIGARD—12420:.'.W. AIN—TIGARD,OREGON 97223
RECEIPT
DATE:,4—; AMOUNT: $ '-
9-
NAME:
ADDRESS: "dizw-) CHECK _
M.O.:
#OF
FOR: ACCT.N PIRMITS SURCNAROE c N,OUNT
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
ZONI G ADJUSTMENTS 05-362
els
- TOTALS
RECEIVED BY:
PERMIT NUMBERS ASSIONID:
Number AmoaM Number Amount Number Amount
i RECEIPT 0 16766
INSPECTION NOTICE
City of Tigard Building Department
12420 S,W. Main St.
Tigard,Oregon 97223
Phone: 639.4171
Type of Inspection `
Date Requcsted_ 'Z r R- RAI Time__. A.M. _ P.M.
iAddress ��G 7-57 .S 6gr Permit #
Owner_ _— Lot #
Builder
The following Building Code deficiencies are required io be corrected: j
I
Presented to - -- -`__ �___.__—_..r-_r..-- •-- pproved �—
j -- _— ,/
Inspector /�J 1/f Disapproved
Date
CALL FOR REINSPECTION
[] Yes /NO
------------
MESSAGES