7520 SW BONITA ROAD FILE NO. '0� STR. OPN. PERMIT
'� BONITA RD 7520 �'
APPLICATION - STREET IMPP 'EMENT/EX.CAVATION COPY TO:
WHITE) -FILE
ORDIN—ACE NO. 74-14 IewE) INSP.
(INSTRUCTIONS ON SEPARATE SHEET) EL LOW) -OTHER AGENCY
INN) - APPLICANT
APPROVED
APPLICATION NO.: ____
NOT APPROVED Ej CITY OF TIGARD,OREGON F'EE AMT.: S �S.
PENDING FEE. PMT'. p CITY HALL REC'EI
PENDING SECURITY p PUBLIC WORKS DEPARTMENT BY
PENDING AGENCY "OK'' ❑ Application and Progress Record
MAINTENANCE BOF(D _0 �~
PENDING INFORMATION p FOR STREET IMPROVEMENT/EXCAVATION AS REQUIRED )o
ANNUAL C3
PENDING VARIANCE 11 ❑ J_ v - EXPIRATION DATE: W11L•,
PERMIT NO '1 ;` —
DATE ISSUED: _.L__L . BY:
(1 ) APPI_ICA I N IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT
NAME A OR1rS9 � _.I`
CIrY PHONE
CONTRACTOR _ CYC YY�.P�
AME ADORE SSS- CITY - PHONE
PLANS BYhrh►
NAMP
- ADDRE9l1 -CITY PHON[
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ :151<'s. C)C_.)
DOLLARS
(2) EXCAVATION DATA: --- --- ------=YrqALL
orFICE USS_._'�_.___=--�0 N0.02 X III
00
STREET DESCRIPTION ROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAT_YPE I_ENGTHWIDTHDEPTH (TEM ITEM DATE REMARKS/TYPE BY
REET NECD N IONUESTIMATED STREET OPENING DATE: / / E SESTIMATED STREET CLOSING DATE: / / TED
(3) SECURITY NO. SECURdTY AMT.: 1 REET
SURETY CyO.: LvsEINAL
CASH CI SPEC. J^tft (
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTENT
11 I I 1
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S) NOTE THE CITY OF TIGARD DOES NOT, HEREBY. GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT-OF-WAY JURISDICTION 15 THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON.
THE APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURITILS. 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.
DATE
APPLICANTS SIGNATURE:
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