11200 SW 72ND AVENUE FILr NO.
=nd AVE. - 11200 STR. OPN. PERMIT
APPLICATION — STREET IMPR( "MENVEXCAVATIONI COPY TO:
ORDINh..CE NO. 74-14 ❑ (WHITE).PILE
IBI_UEI'INSP.
(INSTRUCTIONS ON SEPARATE SHEET) ❑ (YELLOW)-OTHER AGENCVF] IPINKI- APPLICANT
APPROVED U APPLICATION NO.: ./ f
NOT APPROVED ❑ CI1 Y OF TIGARD, OREGON FEE AMT.: >1 *As-
PENDING FEE. PMT. ❑ CITY }TALI. RECEIPTNO.: " ` p 7
PENDING SECURITY [� PUBLIC WORKS DEPARTMENT BY L[I._ DATE 7 [ G L I
PENDING P.GENCY "OK" Cl Application and 1'rogress Record _ _ _ _ _ _ _ _ _ _ _ _ _ — _ _
MAINTENANCE BOND M
PENDING INFORMATION O FOR STREET IMPROVEMENT/EXCAVATIOM AS REQUIRED o
ANNUAL ❑
PENDING VARIANCE ❑ EXPIRATION DATE: /
PERMIT PJO : DATE ISSUED: _—_,�7 / Ic"' IF- , By.-: 1l A
(1) APPLICATION 1S HEREBY MADE TO EXCAVATE FOR AND INSTALL
--_--._-- _ AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT _ —
NAME ---�--- - --�- ADDRESS C I T V PHONE
CONTRACTOR — -------��,_—____ -----__—.-- _____
NAME ADDRESS CITY PHONE
PLANS RY
_NAME ADDRESS .r —.— CITY Z PHONE
ESTIMATED IM.'ROVEMENT TOTAL VALUATION ( COST): S ___
DOLLARS
N.
(2) EXCAVATION DATA: FOR OFFICE USE; f7MI
0.02 .`c i E
STrfEET _ DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFAi-E CUT CUT CUT MATERIAL INSTALLED IT DATE REMARKS/TYPE BY
LENGTH WIDTH DEP-,H ITEM A QUANTITY
STREET
INSPE - T�
-- R TION
E
Q
ESTIMATED STREET OPENING DATE: / / _ ES
ESTIMATED STREET CLOSING DATE: E / / g
STREET
(3) SECURITY NO. SECURITY AMT: $ _ C.LOSE
SURETY CO.: __ __ FINAL
CERTINKOCH[CK ❑ CASN ❑ MOND U INSPEC.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSII:AL _ SPECIAL PROVISIONS/CONDITIONS: /
FEATURES: EXCAVATION LOC".I ILN AND E.TENT. ii'G 1�E�t //�vw wt CT yr��►I t�r�
1 f t I � �� 1 1 I I"�S`ifr i!✓C�
I I 1 I I --
1 I 1
CURB
J
(5) NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHF'RE
RIGHT-OF WAY JURISDICTION IS THAT OF WASH.NGTON COUNTY OR THE STATE OF OREGON.
THE APPLICAN. HGREES TO DEPOSIT YHE REQUIRED SECURITIES, TO COMPLY WITH ALL. PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTIMENT Y'J CONDUCT OF THE WORK, AND TO SAVE HARMLES3 THE CITY AND
EMPLOYEES AGAINST ANY ,NJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS
APPLICANTS SIGNATURE -- __ �, DATE - ,j/ / /
CITY OF TIGARD—12420 S.W.MAIN—TIGARD,OREGON 97223
RECEIPT
DATE: _ A%,101UNi. S /G'
DOLLARS
NAME: y f.- CASH:
yam'
CHECK;
ADDRESS:
M.O.: _ .^....._
OF
FOR; ACCT. PERMITS SURCHAROI _AMOUNT
SEWER BILLINGS 40-064 S
BUSINESS LICENSE 05-331 _
PLUMBING PERMIT 05-332 S --
MECHANICAL PERMIT 05-332
BUILDING PERMIT 05-333
SEWER CONNECTION 40-363 --
I SEWER INSPECTION 40-365
SYSTEM DEV.CHAW-,E 25-366
PARK DEV.CHARGE #1 30-367 --
PARK DEV. CHARGE #2 30-36$
ZONING ADJUSTMENTS 05-362
TOTALS --
RECEIVED BY
PERMIT NUMBERS ASSIGNED:
Number Amount Number _Amount Numbs Amount i �
- RECEIPT N ;;
L -