9280 SW INEZ STREET .`7
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FILE NO.
9280 STR. OPN. PERMIT
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APPLICATION -- STREET IMPT '/EMENVEXCAVATION COPY TO:
L❑ (WHITE)- FILE
ORDIt--NCE NO. 74-14 Cl (SLUE) INSP.
0 (YELLOW) -OTHER AGENCY
INSTRUCTIONS ON SEPARATE SHEET) ❑ (PINK) -APPLICANT
APPROVED APPLICATION NO.: _/ 3
NOT APPROVED CITY OF TIGARD, OREGON FEE AMT.: III Z
PENDING FEE. PMT, CITY HALL, RECEIPT NO.:
PENDING SECURITY O PUBLIC WORKS OEPARTMEMT 13Y _f� t DATE_ 9 L`8/ TS
PENDING AGENCY "OK" C1 Application and Progress kecord MAINTENANCE BOND M 2 S _
PENDING INFORMA BION O FOR STREET IMPROVEMENT/EXCAVATION AS IRE oUIRF o u
ANNUAL U
PENDING VARIANCE L7 EXPIRATION DATE:
1 ' 7.S __ DATE ISSUED: ---"�--1_ 51 _-._ BY: _._-----. _-------
PERMIT NO.: ,� � --
(1) APPLICATION IS HEREBY MADE 'TO EXCAVATE FOR AND INSTALL
____ AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANTapt• lei ` 7 �o (.[.1 ['� — - + oNE`` .'
NOMEC.ONTRACTOR --- ---
NAM[ y� AODRIi58 CITY PHONE
PLANS BY
��19 - --- — -- --
NAME ADDRESS CITY PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ - Q L
DOLLARS _
FOR OFFICE USE: IN.
(2) EXCAVATION DATA: 0 02 x S
STREET DESCRIPTION PROGRESS & INSPECTION S.-ATUS
NAME SURFACE CUT' CUT CUT MATERIAL INSTALLED ITEM DATE SMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM IN QUANTITY
LDrzSTREET
IS I PE
INSPCC-
R TION
E -"
Q
U
ESTIMATED STREET OPENING DATE:--/9 /51107- 1 S — S
ESTIMATED STREET CLOSING DATE: _t2,,Z ��P•f � S E
STREET
(3) SECURITY NO. 25 SE RITY AMT.: S �-'��' CLOSE
SURETY CO.: ! E� Ak' FINAL
CIfRTI VIED CO U CASH p S7ND INSPEC.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS /CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTENT.
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(5) NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRA►�T 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 HEGUIRED 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 A)Y INJUPY OR DAMAGE WMICH MAY RESULT FROM APPLICANTS ACTION-
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APPLICANTS SIGNATURE: .� �r BATE �� 1
i CITY OFTIGARD
Date Amount a:L4:9 0 u
dollars
Name
Address "^� ! Check
Bldg ❑ St.opng. E] Bus.Lie. ❑
❑
Plop. ❑ Pubetns. - ❑ Bike lic, -
f{cil. - ❑ Copies - ❑ Sew.Serv. ❑
Sewer ❑ Filing ❑ Fine&F. ❑
Assmt, ❑ other - ❑ Zoning ❑
For:
Permit s' /_.'-7 br ------
CITY OF TIGARD
WMITCN[N►111N TING�7f A T10N[IIV
12669
AGENT'S r_OP'f
HALLMARK '' 7/
INSURANCE COMPANY � �rrr �,i.herE l nmf�nn�
P.O.Bo.5269-Medlson,Nit 51705 (�/ / �G`� MANAGINI'b GFNRRAL AGENTS
Telephor+e 608/834-5901 P.O.Sax 130•sea-zi.en,Oro.97005
Tolex.26.5o'f, Q�-�' `�fL�� Telephm 1,01'6414811
�J 'l Tele._.36030!
PRODUCES Foley Insurance C�c'\,�GpP`GO
3800 S.W. Cedar Hills Blvd., Suit 0 ��
ADDRESS Beaverton, OR 97005 F�ap P�,o BOND EXECUTION
N.) REPORT
Iq
PREMIUM NOTICE
The term for this bond expires on the date
Richard C. Hathaway given In the box b?!ow. Your NET check for
PRINCIPAL dba So West Paxtition 6 Construction Co. the renewal premium of$ ____2OQ,9-0—must
ADDRESS L1ur.'.S 14'..; Dogwoor., iij.� L�uor�o,on 97123 be received on or before __ 3-15 1975-_
in order to avoid cancellation.
OBLIGEE State of Oregon If cancellation notice is sent, an additional
fee of$10.00 will be charged for reinstatement
TYPE OF BOND Contractor's License
Premiums fully earned upon issuance,except In even+
7 (,� of cancellation by Company. in whl i event pro-rnla
t
Bond No. 11B 11255S credit will be returned.
+ 2-PENALTY � 4-TERM. CONTINUOUS
S EFFECTIVE 4^15-75
200,00 $3,000,00 NEXT PREMIUM DUE DATE,4'1577