9550 SW LEWIS LANE-1 FILE NO.
LEWIS LANE - 9550 STR. OPN PERMIT
MY OF TIGARD
EXPENDITURE RWJFST
RwJFST
'Ibis form is a multi-use form. Appropriate receipts must be attached. Documentation
i--*. important for all purposes. staple documentation to form.
VENDOR R).: DATE: cl
PAYABLE ID: RI.MJMTM BY:
9 y V17
--J-1 OV-1 Approved reclu(--t due Wednesday
10:00 AM to A/P for checks by
Friday.
MICRIMIAND7U-3. 1`
Date Description, Invoice No., etc. Ac oaunt No. Arr)unt
IC) OO$
'MrAL
Mi lenge $0.255
APPROPRIATION BAIMCr.: X3 OF: SIGNMURE:
(Up to $25.00) Section Manager Purcli. Agent
(-,^!25.01--2,500.00) Division Kinaqer
($2,5UO.01-7,500.00) Dept. Ikvid
($7,530.01-15,000.00) City Administrator
($15,000.01- ?) ix-jr-al 0ontrac-t Revi-04 Board
ke/1501F
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�� Is r� �u�U C��'✓1�
APPLICATION -- STREET IMPRO` HENT/EXCAVATION CQPY TO:
ORD .ENO. 7WI1ITE.)-FIt_E
4 14 IP1111bMW),INSP.
(INSTRUCTIONS ON SEPARATE SHEEN)
U OlhK) .OTHER AGENCY
'`�!1'F*1-APPLICANT
APPROVED IK APPLICATION NO..
NOT' APPkOVED [] CI I Y OF ]IGARD, �)RLIGQV FEC AMT. S # �
PENDING FEE PMT. 13 CI IN' IINL.L RECEIPT NQ.. --ZOO/2e (�p�
PENDING SECURITY ❑ PUBLIC WOhKSDEPARTMENT BY :.! DATE S to / oma
PLND'NG AGENCY ''OK'' (] Application and Progress Record — —
MAINTIiNANCE BOND N_
PEND NG INFORMATION O FOR STREET IMPROVEMENT/EXCAVATION As REQUIRED
ANNUAL U
! EfIDINC, VARIANCE L] EXPIRATION DATE:
PERMIT NO � DATE ISSUED �1�.[ �_ , BY.,•�.
( 1) APPLICATION IS iEREBY MADE TO EXCAVATE FOR AND INSTALL _�' F=-
-. AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
ICAN T
N CITY FNONt .
Lf),' : RAC TUR . CITYw�€---
PL.ANS BY
NAME.._ _... 'ADORES9� ._ CITY ONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST):
DOLLARS
FOR OFFICE USE: — •-MIN.
(2) EXCAV,ITIVN DATA. 0.04 X s
STREET DESCRIPTION __ PROGRESS & INSPF_:.TION STATUS
SUa,FACE CUT CUT CUT MATERIAL INSTALLED
NAME TYPE LENGTH WIDTH DEPTH ITEM & QUANTITY ITEM 7)ATE REMARKS/T'Y-E BY
C4M STREET -
OPENED
II C- —
R TION
E _to
ESTIMATED STREET OPENING DATE: q -51
ESTIMATED STREET CLOSING DATE: E — --
_...
(3) SECURITY NO. ('C? tOr=— STREET
SECURITY AMT.: S �._—____ CLOSED
SURETY CO _ FINAL
CERTIFIED CMECN `bOND� INSPEC.
(4) PLOT PLAN INDICATE SITE PERTINENT PHYSICAL w SPECIAL PROVISIONS /CONDITIONS.
FEATURES, EXCAVATION LOCATION AND EXTENT.
/-0 ✓'i•-C' e fYd f
1 I 1
I I I
---- _ vt_o r
9 S SO I I
S) 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 APPLICANTAGREES TO DEPOSIT THE REQUIRED SECURI CIES, TO COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HAR'ALESS THE CITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS
APPLICANTS SIGNATURE `►_LL f 1 . i (Y . A ADATE
.n 'y
•�
I
CITY OF TIQr4RU R.Er.:.E IPT OF FAYME,,
rw RENHT'H RIPACV' r<E UFIF'T NO: 001 01Wf-4
A '.i=`_:' 1'350 Sri LEWISLANF PAYMENT DATE: 08-up-'160
1 IGARD., OR q72.23 81-06.. NO/ADDR:
`i p'Ur1E?09E `b p (,WT' AMOUNT PAID PURPOSE f._1F f✓AYM8NT- ', ,�; AMOUNT PAID
-•----_.. ___�. ��__�___�__�__.__ __._____-_-.__ ______.----._______.__ _--__- -----._--_--
CU_TQ1,lER DEF"O-SITS FUEL-I C I MF ROVEMF_NT PERMITS Al . fJf]
1 ,
I8 A f,EP'VNUAHLE DLP05IT
TOTAL. AMf)1_rNT F'AID 104.U6
i
i
nENATE HIBACK 5050
9550 SW. LEWIS LANE 820-8281
a
TIGAPD, OREGON 97223 _._ _ �_t9_�! 24-12310239
PAY 10 THI
ORO[R O7 ._L 1 Y < ._..I ij c(-.lel_
n,)I I Ak5
a FI1'*t a 0 egontN Bank
of Oregon, .A
InterslatQ Tigard Branch
P. Bow 2321,
��311k Tlgerd,OR Q7223
k e/3 5 7 4 P
1: L 2 3000 L 2 31:4 3q 001.404 0,1'' 0 5C1
ice' K/rllall[!I.N.a�aa/-. -aA�r- :sr i"f•!�9MYR��J l�Y
PLEASE IriKE. T-JIG TO THE CAS I IELR FOR I) RIA:'I If'[
PAI U
NAM[ 0 ------
ACC', # DESCRIPTION AMOUNT
10 - jo Refundable Performance Bond_Deposit ___ /trip
10-43600 Public Sewer Plan Check/Inspection F0Q_
10-43600 Public Storm Plan Check/Inspection Fee
10-13600 Street Dedication/Public Im2novemenLJee
10- 43600 Street Opening Permit r-,
10-43600 Street and Traffic Mark
21-44200 Street Light Fee
10-43700 Sign Permits $
10-43800 Land Use Application Fees
10-22000 Refundable portion of Appeal Fees
10-45100 Document Sales :
Engrg. PlannjM_ _____.Bld
10-45200 Park Reservations
10-43000 Business Tax
TOTAL $
RENATE RIBACK 5050
9550 SW. LEWIS LANE 620-8281
TIGARD, OREGON 97223 ig 24 12 439
1230
PAY 1`0 tHt
$ Ci
D 0 1, L A R 5
FIrst Interae Bank
of Oregon.tmN A
aMist intetvtofe Tigard Branch
PO Box 21P18
Tsg,1(d.On P1223
ke/3574P 1,41 MO
1: 1F300042311:439 004404 Otis 05
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