9395 SW JULIA PLACE-1 EXILE NO. 25 -1 -8-7
JULIA PL. - 9395 STR. OPN. PERMIT
CITY OF TI 7-A RD
EXPENDITURE REIMBURSEMENT REQUEST
T1 is form is a mulct-use form. Where appcopriste receipts must be attached.
Ducumentation is important for all purposes. Staple docLmentation to form.
VENDOR NO: _ DATA:_ ! L`T _ y 7
PAY,'t.BLE T0: ����„ )s �.ut. I� '< '�y[+'+P �� �c iP. Requested by:
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MISCELLANEOUS (perking, books, subscriptions, dues, memberships, etc. ) :
Date Description Account No. Amount
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GENERAL. MEAL EXPENSE:
Date Description Amount
Account Number to be charged: _ Total
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MILEAGE:
DateDescription: (Include end/start readings and total miles) Amount
Account Number: Total miles x _ . 20
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APPROPRIATION BALANCE A.ti OF : Signature
AI'I'kt)VALS ( if $2 ,. O() ,n.lrt n,,r hr t .• r•nhut •.r.1 thtuugh petty iash) :
(up to SSOO. 00) / .,.. Na..avrr IrutCh. Akent
RENnISSAWE DEVELOPMENT (ORPORATON
Rundal S Seb(..,aam
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2043 Ujoldai Stror- • UJ"Lkin.OP 9*7068 0 (503)6SI.5739
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APPLICATION - STREET IMPP 'EMENT/EXCAVATION COPY TO:
(WHITE)•FILE
ORDIN,-,INCE NO. 74-14 YELLOW)•INSP. 1
(INSTRUCTIONS ON SEPARATE SHEET) PINK)-OTHER AOENCY�LIdt�r
(BLUE)-APPLICANT
APPROVED APPLICA(ION NO.: - I b
NOT APPROVED L; CITY Y OF TIGARD, OREGON FEL AMT.. E_. �L• __
PENDING FEE. PMT. ❑ CITY HALL. RECEIP p. _ ZZ.74`!
PENDING SECURITY Cl PUBL IC Wrl RKS DEPA R TMEN T BY _ DATE_ L,_ l 4 i. 7
PENDING AGENCY ''OK" ❑ Application and Progress Record
❑ MAINTENANCE BON
PENDING INFORMATION
FOR STREET IMPROVEMENT/EXCAV�-,TION �s Rr��u�vF 1,
A NNUA I- U
PENDING V ARI ANCE L7 EYPIRATi N PATE:
PERMIT NO.: � � _1— DATE ISSUED �_L¢_L ��?_-, BY:
(1) APPLCATLINIS EREBY /ADE TG EXCAVATE FOR AND INSTALL_- e-� AS DESCRIBED HEREIN, IN FULL ACCOR ANCE WITH CITY REQUIREMENTS.
APPLICANT
Cl/T1Y HONE
CONTRACTOR —.SCJ
N F ADDRESSCITY PHON
PLANS BY "_' � �:3 -` —
NA 6 ADDRLSS CI RHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $
DOLLARS
(2) EXCAVATION DATA: PDR OFFICE USE: – ..v ; ININ.
0.04 x $
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH ,{WIDTH DEPTH ITEM & QUANTITY
STREET
INSP
R TION �'L i ;/.•*• ^.��:t
E
ESTIMATED STREET OPENING nATE:��' / --'� �_ `�'_ _y S frN-t /f/t _
ESTIMATED STREET CLOSING DATE: �.—L__ ED
_ �O/1� STREET
(3) SECURITY NO. ------- SECURITY AMT.: s-_ ` CLOSED
SURETY CO.: _ FINAL
CERTIFIED CHECK It CASH GOND lINSPEC.
(4) PLOT PLAN: INDICATE SITE PEr'TINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTENT.
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(5) NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPIERE
RIGHT-OF-WAY JURISDICTION IS THAT OF WASHINGTO 1L)OUNTY OR THE STATE OF OREGON.
THE APPLICANT AGREES TO DEPO E UIRC C„jJRITIES, TO COMPLY WITH ALI, PERTINENT LAWS AIVD
CONSTRUCTION SPECIFICATION RTI O OF THE WORK AND TO SAVE H,,RMI E4S THE CITY AND
EMPLOYEES AGAINST ANY RY O (ICH MAY RESULT FROM APPLICANTS ACTIONS
i�
APPLICANTS 31GNAE �` _ DATE `/
Ti6Al�p N Q. 22949;-
P.O. B.W.HALL BLVD.
t>tOX 23307 , Date
P.
Ttt3/►RD,faR AT'M
Name
Address
Lot BlooklMap SubdlvialonlAddreas
Permit#'a Bldg. Plumb Cash Check
Sewer Other Other FeC. By
Acct. No.
Description Amoun!
10432 Building Permit Fees_
10431400 PlumbingPermit Fees
10431.801 Mechanical Peff-I Fees
10234501 State Bld .Tax
10433 _ Plans Check Fee -- --- -
30.443 Sewer Connection
3p,441 Sewer In tIon___,v____�__
51-448 Street S .Dev.Charge
52 41 10 Pantie l Sys2. Dev. Charge ^_
2.449JM Parka li Syst. Dev. Charge =���
31450 __,. Storm_Dnlnoge Syst:Dev. Charge
r 10430 Business Tax
10434 Alarm Permit -
102zT� --
10455- Finer - TrafficfMiedlParking
1 230 CPT,TfaffIctMisdlVic. Asst. ,
10.458 Indigent Defense —37--12-2-.-4-6-1 Sewer ServlcelUSA
30-122.402 Sewer ServlcelCity 30%
3 -123 Sewer SevlcelCity Mafnt.
x•125 Unmatched _ ___
1-1 4 torn Dra;nage
4 -- Pncro t Prin. Pymt _
4-0-471 eancroll Inert 'y_mf.
_ TIDTAL
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CUSTOMER
I
PLEASE TAKE THIS TO THE CASHIER FOR A RLC:EIPT
NAME: �E?,�� �s�L„c-e- 4-4
I)e_\/CA %AeAA Cin-Q, DfT�.:_ ����L+ L e'- 7
-ACCT, N _s DESCRIPTION AMOUNT
10-7.2000�� __ Refundable Performance Bond Deposit $ _ 6o
10•-43500 Sign Permits HOP _ TU
10--43600 Public Sewer- Plan Check/Inspection Fee---_ $
10-43600 Public Storm Plan Check/Inspection Fee _ $
10-43600Strut Dedication/Public Improvement Fee
10-43ti00 _ Street c)�eninq Permit ZS4 _ $�`
—_. _ . —. —
10-43601 Street and Traffic Marking
21-44200 Strael, Light Fee _
10-43700 Subdiv 3331
�'�."►-�� RUN.4.IsbANC OEAor-I
ENT (CORP vza,$,141 � ���— �_ DD
DF,NELOPM ,,u. (593)9 W. 110ONZ141+cpteY 972
Pay to
Order_ ,� ��" _��._—•-
Bptr•t • P N° ell .9
r ponw
JO 5a R0
Ba►x'< 12
0.0000 3
3 3 `0.. �: L 2 3000 2 3l:5 L 5 - - -
101 AI $ Z!Ly
1045P/0023P