11495 SW GREENBURG ROAD }I� FILE NO.2S1"81e) STR. OPN. PERMIT;
GREENBURG ROAD - 11495
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CITYOF TIGARD
EXPENDITURE REIMBURSEMENT REQUEST " `i'�• (
This form is a multi-use form. Where appropriate receipts must be attached.
Documentation is important for all purposes. Staple documentation to form.
VENDOR NO: DATE: 7 Z
PAYAB).E TO: jt,\A , v� ____t� Requested by: ti
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MISCELLANEOUS (parking, books, subscriptions, dues, memberships, etc.):
Date Description `
` Account Nc. Amount
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GENERAL MEAL EXPENSE:
.Date Descri•tion Amount:
•
Account Number to be charged: Total
_,_,-- _ .• rarest. - -
MILEAGE:
Date ' Description: (include end/start readings and. total miles Amount
Account Number: Total miles x$.21 t
APPROPRIATION BALANCE: AS OF: Signature
APPROVALS (if $25.00 or under may be reimbursed through petty cash):
(up to $500.00)section Manager Punch. Agent. _
($500.01-$5,000.00)Dept. Head/Purch. Agent
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APPLICATION -- STREET IMPP 'EMENT/EXCAVATION COPY TO:
ORDIIt.ACE NO 7414 (WHITEFILE
(YELLOWW)•INSP.
(INSTRUCTIONS ON SEPARATE SHELT) (PINK)-OTHER AGENCY
+ it (BLUE)-APPLICANT
APPROVED `/7`_3 APPLICATION NO.: __ 23
NOT APPROVED (] CITY OF I IGARD, OREGON FEE AMT.: $ .._ 1l-,._o ---
PENDING FEE. PMT. (j CITY HALT. RECEIP ___ 3Z.v f 1
PENDING SECURITY 0 PUBIICWORKS DEPARTMENT UV DATE_ 4 i 14/E£5
PENDING AGENCY "OK" ❑ .Application and Progress Record
MAINTENANCE BOND *.—
PENDING INFORMATION ❑ FOR STREET IMP VEMENT/EXCAVATION As REQUIHEo 7sq
ANNUAL 0
PENDING VARIANCE 0 EXPIRATION DATE: t. Jr'a-4,-
PERMIT NO.: __28.7-ege DATE ISSUED: �'_ //'f'/ �� .. BY. -.__. ..t. �
(1) APPLICATION IS HEREBY MADE -10 EXCAVATE FOR AND INSTALL C- A P-/_ick__ __ _ _ _
/WAD__ AS DESCRIET.D HEREIN, 114 FULL ACCORDANCE WITH CITY REQUIREMLN Es
�j�' '' � // .•4l' 77 ..
APPLICANT _.$IIJS/._.i L . D'.'.l��SlAIAA/ //��5 �G4,UY'v`lyN�$d�G- /2.4. 77.11-/4-q 1)..._.__
^ NAME ADDRESS —CIT PHONE
CONTRACTOR 4 - Z OW/46-_...-
NAME ADDRESS CI V---____.. __.---16.1ONe----
PLANS
-
PLANS BY t/7 '_ 3
NAME _...___ADDRESS.-_. CIT''- _._._..HONE-
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ 35v,00
DOLLARS
(2) EXCAVATION DATA: — �- - -vON OPFICE DIE:-`-0:� -:-,"vv MIN
STREET _ DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLEI:, ITEM OA TE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM AI QUANTITY'
A STREET
L�ft21�+Bi Ir'lE'Gr ,c. J,5 'x JL / td-_A C. E TION �^
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ESTIMATED STREET OPENING DATE:..__ {c.�_ 7 ,/9 7 `se g
ESTIMATED STREET CLOSING DATE: ____ ' 1 /s 1 T
E
_-- STREET
(3) SECURITY NO. ______ AMT: $ J-C _ cLosr D
SURETY CO. _ - ' _ FINAL aI ^ / .
�� X INSPEC.L' II F� yil�J 7Ge/C ✓' �G
(HECN CASH C.1 BOND r . �'
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS:
FEATURES: EXCAVATION LOCATION AND EXTENT. (1)
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(5) NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLIC ANTS 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 WITH ALL PERTINENT 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 ACTIONS.
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APPLICANTS SIGNATURE _._ I! �/ ( A -, 11 DATE__L,t 17 I by L_
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• MOO131,151NISt N%1MS
SPEEDISE1 m S
MCP.,PATENTS 3.016.308.3 429.821
art OF TIGARD No. 32071,
13125 OX HAL L BLVD. 1(f '
n�fAli�I� P.O. BOX 23397 Date � ff '
TIGARD,OR 97223
_________ V LazionazI__________.
Name
--
Address --
Lot Block/Map- Subdivision/Address
•
Permit #'s Bldg.
Plumb Cash Chret 6U / 0'1
Sewer
- - - ---- -- Other Other Rec.�`,
- -— - Descr --- Amo 1
Acct. No.
10-432 Buildin• Permit Fees --------- „
10.431.600 Plumbin Permit Fees
10.431-601 Mechanical Permit Fees _
10.230-501 State Bldg.Tax -
10-433_ Plans Check Fee - --- --
_ 30-443 Sewer Connection --_ - --
30-444- Sewer Inspection ---
51-448 Street Syst- Dev- Charge _ --
52-449-610 Parks I Syst. Dev. Charge -
52-449.620 Parks II Syst. Dev. Charge
31.450 Storm Drainage Syst. Dev. Charge -_. ____-__
10-430 Business Tax —_—_---
. 10-434
- --
10434 Alarm Permit
_________________—_—_--
-10-0'7
____ ___ ---
10-227 — Bail —_- --
_10-455- Fines - TrafficiMisdIParking _ ___--
10.230- CPTA TrafficIMIsd/Vic. Asst. ____• --
• 10-456 Indigent De'.inse
30.122-401 Sewer Se,•+IceltJSA ---___
1
30-122-402 Sewer Service/City 30% -_-_ -
` 123`-- Sew SevicelCity Maint.
30.125 - Unmatched -___-
--31 1 4- Storm Drainage -
01P75 Bancroft rin. ym1. —
-40-471 Ban oft Int.py 1. -
_______
__
70-_---.4, ,___Tai . 1 �C
' L TOTAL 1110 Ytd:
ACCOUNTING I
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PLEAS!. AKE THIS TO THE CASHIER FOR A ( IP1
NAME: J,S I)1 L'71-er eia N _ DATE: 6//41fee
ACCT # � _ DESCRIPTION AMOUNT
d-c)
22000 _.' Refundable Performance Bond Deposit i gSQ.
:0-43600 Public Sewer Plan Check/Inspection Fee /_____._
10-43600 Public Storm Plan Check/Inspection Fee $
10-43600 Street Dedication/Public Improvement Fee $
I 10--43600 Street Opening Permit // 2£3-7--SF $ l4.
10-43600 Street and Traff+^ - $
21-44200 gGNI�uP�G (2D 036 $
5
5-7.0 6/ N ay.2.3 2
rr.-A.° / F'�-6°,' S'yL 6 I4 y $ '�� ` s
J. & D �1 pp,NGou$1 v .� 000-APs
APPYkiwI
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1 /" 0
80NNa4M...110�o� 0
, 1110Np. 0NU pEot1,r 6 Bq. fJ 8
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uNTtO• ►T,• Dpliiiatr 01AC1 Z
$
FOP rrk" Z20t. 0I6
4%I °00 _ ousiness Tax $
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TOTAL $ j ,4.
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��cr ►�� 0388
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APARTMENT ACCOUNT $
.�t� F 716-6A-b ----------- oar i-APs
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MAN IA $ t L+
1111/141A"'"":610.13,
1bA^D_iMANOM A110,01t�1ttN eDiii',v,r N
RO•�pfl t! ?LYWO O.011000
UNIT•O•TAT••NATION• [1
roR (�tJN7 ���� p�6 0 t 3'3 B 2B°' 0 C7
a; L 2 3000 2