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8840 SW REILING STREET FILE NO. REILING ST. - 8840 STR. OPN. PERMIT CL of TlFAF)J) EXPENDITURE REIMBURSEMENT REQUEST This form is a multiuse form. Where appropriate receipts must be attached. Documentation is important for all purposes. Staple documentation to form. VENDOR NO: DATE: Z-19 —c97 PAYABLE TO: Qobe�UC�P �CaY� �. C.S Fol Requested by: S,t,�. Ret 1 i.so► _ ...v.v...........r................w...r.........wi..........w................... MISCELLANEOUS (parking, book3, subscriptions, dues , memberships; etc. ) : Date Description Account No. Amount — ado _ fes' ...w..v....w...........rw........r....r........v......u..................ar_ccc,_..¢n GENERAL MEAL EXPENSE: Date Description Amour t. Account Number to be charged: Total .rwww.......1.....am..................... MILEAGE: Date Description: (Include end/start readings and total miles) Amount ( ^ccount Numtler: _ Totalmiles x �.Ry w _ wwww.w.r.ww.w.•r..r.w.rr.r...w....wrw.www.w.wwwwww.www..r..w.wwr...wwr....w...a APPROPRIATION BALANCE: AS OF: Signature APPROVALS (if $25.00 or under may be reimbursed through petty cash) : (up to 5500.00)Section Manager _ Purch. Agent ( 000.01-1:,000.00)Dept • Head/Purch. Agent APPLICATION -- STREET IMPR -MENT/EXCAVATION `COPY TO: ORDINANCE NO. 74-14 (WHITE)-FILE (YELLOW)-INSP. (INSTRUCTIONS UN SEPARATE SHEET) (PINK)•OTHER AGENCY )X(RLUE)•APPLICANT APPROVED APPLICATION NO,: ZfoZ NOT APPROVED LI CI I Ok I WARD, OREGON FEE AMT. S ._--jeaz0-10 ` -� PENDING FEE. PM'T. ❑ CITY HALL. RECEIP PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT BY _ DATE -3 / Z.7/!4� PENDING AGENCY "OK" Ej App'ic'ation and Progress Record — — — — — — PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION MAI ASE EAONG EBor Dx.�_____,._____ PENDING VARIANCE [] ANNUAL_- EXPIRATION DATE: .. C C ><r PERMIT NO. 3 — w DATE ISSUED: Z-j Z7� � BY: (1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND4*ff-At+- Coy I eck CoyA %M h�I1r� AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS. APPLICANT . 'Zc2• AS e _3 67 �� �I�� (au �s19 I'A 7c CONTRACTORCITV PHONE�'��""-�— © N A M ._.-�_._-___ D O R F SS .._.--. ---_�_• j—•-- --._-�r H O fV'��_. PLANS BY- - Lam' c S�a_C.�S N� E A DRiSSI ffJ CITU ----FHpNE ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S DOLLARS (2) EXCAVATION DATA: FOR OTCK r:� 0.04 X OT - iG� _ :_ g•�i' S=ESU DESCRIPTION PROGRESS & INSPECTION STATUS TYPE F CUT CUT CUT LENGTH �CU�H DEPTH MATERIAL TEM IALE AIIQUANLTITY /TYPE BY ITEM DATE REMARKS S +ti a. ( ( �• ,� I M : STREE INS R TION E O U _ ESTIMATED ST'7E!T OPENING DATE / ZP� / E S ESTIMATED STREF, CLOSING DATE: _ / / T ---- E (3) SECURITY N S CURITI AM :: E 00 �= STREET a CLOSE ( %4 SURETY Nrc r•INAL �-�- CERTIIIEO CI-IECK --- - / a0Nn INSpEC. 1 R Y� L t (4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL - SPECIAL PROVISIONS CONDITINS: FEATURES; EXCAVATION LOCATION AND EXTENT. - t URB - itAr ` \C_ ` a C_11w 5 NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO COMDUCT WORK WHERE RIGHT-OF-WAY JURISDICTION IS THA'i OF WAtHINGTON COUNTY nR 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. APPLICANTS SICNATURE DATE 1 / 4 cv cn ol W cn w .y I N N 3 F- ILbZ CI oN 13,Ob b1�0 51 fM,ob 0 u 09 DU ov 001 OC z U 0 z a pi O� o o m N t0 at 0 + N DO 09 8t O ♦ � \ y�1 .�, _ O BG 69BF in 'l� tQ b ^Ir 6Z'►9 { P '1S, ON 1 `113a�'M'S 9ft n O 9 ✓ O O \, L '02 (D 90'601 ti o A OD n 0 W 9 B` m S Ld Fl jIV LbZl[ OL B Gbl 10917 Ot Ot ^t CL a ' O �O SO tlN in inU a' }�1�y� 0 O N 0 Lf) CID Ln N N 2�B C6 L.-j- ° �n 0 O Nr- FPS a 10'99 L 01 OL 99'09 do ' M 3Ad HISS ' 'S x \ in 62'x6 c� b �ab6'9S Bt 69'99 OL _ 10 �-y n ., ♦ r- a' N N NL f ti N N CD ID N Q �`` M 7 t- am Lo" 0909 OL 96'94 ,n CCWS� M b£'Bil 011 9 '911 a n �Cll O It N p t=j tb - 1 r r0 \ \99't01 - F2 Chi - n oir OCD CDpL. m 0 -r -�sas'S'�91H - r ... (ID a 6` r `9S'' V n LJ H1C�t! M5 y� 40 :2 w �9r, Of;11 a Ar tib9auN 2.i�9i P c0O C9 M Q + Q ° }1 O� "' M7 LD p - P� m n U C g Or N 81 C7 - ILD to � c1� n 61'001 o CTJ m t�1 /d a z t! °`O /�/ 1 : tit ~ O ' Qcc �Z' ,_ L+ i co O cD re) 14601 _ .. O4, 41 N � rn lip" v� M O U U W 0. W i C` U o 2 N m R1 O ). O Z ❑ 2 Z Ll Q ,r o a ar W z z [7 T N I o U ~ W U a N } LLJ Z o = - i W v - a W n - - Q- Ngo f (~„' of z ` Q 0 — i ! c� X J � a < Q o o • ' O I � i r 7 1V pi n W V W \\ r U) Q W > W � a w f L`' CD S I 0_ (� Q N (O co O It (O (u Q N (C 2 Q (U O O N N N N N N M M M M M V V qt (n l(I 31w Ld a w z I `� w i _- _ - f-' , _ li m N N (O ap 0 It (0 r_ o M N q, < Q N N N N M M M tf it x LLJ I Q Q S` � Q C PLEASE T,A�KE�i�'T�S 1TO THE CASHIER FOR A RECEIPT NAME: DATE VAoe�A Q, ACCT. N DESCRIPTIO — � AMOUNT 1�:Z Refundable Performance Bond Deposit S ZOO,�— �- 10-435 _ Sin Permits HOP TU 1G--436 Public Sewer Plan Check Inspection Fee s•_ _ 10-436 Public Storm Plan Check/Inspec4.ion Fee 10-436 Street Dedication/Public Improvement Fee 10-436 Street OpenLM Permit 10-437 Subdivisi,,n Applications: S MLP 10--440 ZoninS Applications: ZC CPA ZOA Pi, SDR Misc SCE 'CU _.— SLP V- - 21-44; Street Li hq t '_ee --- 10-451 Document Sales: Engrg. Planning ____H_ldI, .---�..___ --- 10-451 Street and Traffic Signs TOTAI s ZOU5 (1O45P) I ISI k: C' v�C e �F I CITY®F TIOARD No. 12067 12755 S.W. ASH P.O.BOX 23397 hate_r NGARD,OR 97223 Name Address Lot Block/Map Subdivision/Address Permit Ws Bldg. Plumb Cash Check • i t L� Sewer Y Other Other Rec. By AcNo. Description Amount ct. 10.432 Building Permit -ees 10431-600 Piumbin 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. Char e _ 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 Alarm Permit 10127 Bail _ 10-455• Fines 7rafficlMlsd�Parking 10.230• CPTA TrafficlMisdlVic. Asst. _ 10.456 Indigent Defense 30.122.401 Sewer Service/USA 30-122.402 Sewer Service/City 30% 30 123 Sewer Sevice1City Main_t_ _ 0125 Urmatcned 31 124 Storrs Drainage 40.4 i Bancroft Prin. Pymt. 40.471 ancroflIlnt.Pymt. _ TOTAL J � � I �„ CUSTOMER