11190 11240 SW 72ND AVENUE FILE NO. Z'AC)'�5L,
72ND AVE. - 11190 & 11240 STR.OPN. PERMI`.
CI"'Of__TIFA RD
EXPLNDITURE REIMBURSEMENT REQUEST
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: :i�A 'Z0
PAYABLE TO: �eCg, �1N��_ �� Requeste&. by:
................./...............................................c..c acc.vzcacvc
MISCELLA.iLC US (parking, books, subscriptions, dues, memberships, etc. ) :
Date Uescri tion Account No. Amount
GENERAL MEAL EXPENSE:
Date Description Amuunt
Account Number to It charged: Total
MILEAGE:
Date Description: (Include end/start readings and total miles) Arn :i,t
Account Number: Total miles x . 20
APPROPRIATION SAI %NCE: AS 0F: Signature_ _
APPROVALS (if $25.00 or under may be reimbursed through petty cash) :
(up to 1500.00)Section Manager _ _ Purch. Agent
( $500.01-15,000.00)Dept . Mead/Putch , Agent
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APPLICF TION - STREET IMP' /EMENT/EXCAVATION .C�QPY TO:
ILE
ORDINANCE NO. 74-14 +(YELLO • -IN
'WIP(INSTRUCTIONS ON SEPARATE SHEET) (B UE)APPL CANTNCY.rW9
APPROVED APPLICATION NO.: 'e�
NOT A 'ROVED � [] CITY OF TIGARD, OREGON FEE AMT.; f _.._�.��. qP
PEND G FEE. PMT-, CITY HALL RECEIPT
PENDING SECURITY F- PUBLIC WORKS DEPARTMENT BY_10-- DATE _-7 LZ / 8ls
PENDING AGENCY "OK'' ❑ Application and Progress Record MAINTENANCE BOND +M
PENDING INFORMATION 11 FOR STREET IMPROVEMENT/EXCAVATION AS REQUIRED
ANNUAL
PENDING VARIANCE ❑ // EXPIRATION DATE: OKe-
PERMIT NO Z40 -15(1 DATE ISSUED. _ 7_1__Z1- (P BY: __--- --. -_- _
(1 APPLICATION IS HE EBY MADE TO EXCAVATE FOR AND INSTALL.
(0 t4 �_��— AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
ANPeKSOM 1/6 /1 94y L.C$$ek." Pa#_tLA&P 2q5--e3-FS
/{p��Gaa4�d! NAME ADDRESS CIT— PHONE
CONTRACTOR _ AaeA c. 10L if 4121 0 PLO k.,C _ 0/PtLrF�A/pj .?P
NAME ADDRESS CtT 17�I HE
PLANS BY ._ C s A� �K bs
�ME ADDRESS CIT FMONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S _9642--Lz X # dO,
DOLLARS
FOR OFFICE'e0 77-!
— 4 CHIN.
(2) EXCAVATION DATA. 0.04 X
STREET _ DESCRIPTION _ PROGRESS &. INSPECTION STATUS
NAME SURFACE CUT CIiT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WILTH DEPTH ITEM & QUANTITY
22N STREET
- _ (p S 744 SGa.J r i C OPEN _
R/Vp INSPER
V R TION
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ESTIMATED STREET OPENING DATE:_ 2LZ 4'L S
ESTIMATED STREET CLOSING DATE: 72T 3 ��+' E
(T) SECURITY NO. SECURITYAMT: S BDO� STREET
-:LOSED
SURETY CO FINAL /- /�
1,14 CASH CASH 0 BONG C INSPEC. N•�S'� (.•��` V
(4) PLOT PLAN INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS:
FEATURES, EXCAVATIO J OC.ITION AND EXTENT.
aIle �' (�� - - - - ._ - _ - - - ,� _ - Z. �p.�lAti !��•►�yl'1< �ILsLIG
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I5) 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 7EPOSIT 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 ACTIONSAN .
APPLICANTS SIGNATURE ___`-^, DATE C
CITY OFTIGARD No. 14808
12755 S.W. ASH
P.O.BOX 23397 D9118
TIGARD,09 97223
Name r
Address `
Lot Block/Map Subdivision/Address
t Permit M's Bldg. Plumb Cash Check
Sewer Other Other Rec. By
Acct. No. Description Amount
10.432 P,uilding Permit Fees
10-431.600 Plumbing 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 Alarm Permit _
10.227 Bail
! 10.455• Fines -Trafflc/Misd/Parking _
10.23C- CPTA Traffic/Misd/Vic. Asst. _
10.456 Indigent Defense
30.122.401 Sewer Servlce1USA _
30.122.402 Sewer Service/City 30%
30-123 Sewer Sevice/City Maint.
0 125 Unmatched
31-124 Storm Drainage
•475 Bancroft Prin. Pymt.
40.471ancr�ln—pmt.
�.---— ------ ..� TOTAL
T� CUSTOMER
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PLEASE TAKE THIS TO THE CASHIER FOR A RECEIPT
NAME: b Q A Lv% kA _ DATE: -7 --Z
ACCT. DESCRIPTION AMOUNT
eco
C10-220 _ Refundable Performance Bond Deposit
10-435 Sign Permits HCP TU $ "�
10-436 Public Sewer Plan Check/Inspection Fee $
10-436 Public Storm Plan Check/Inspection .Fee $
10-436 Street Dedication/Public Improvement Fee $ _
C 10-436 Street Openi<<g Permit
10-4.37 Subdivision Applications:
S _MLP
10-438 Zoning Applicati.ono:
ZC CPA ZOA PD Misc
SCE CU SLPy $ i-
10-440 Other Planning Fees:
SDR
Non refundable portion of Appeal Fees $
10-220 - Refundable portion of. Appeal Fees $
2i-442 Street Light Fee $
10-451 Document Sales:
Eng_rF Planning Bldg. , $
10-4.51 _ Street and Traffic
( 1045P)
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