11240 SW 72ND AVENUE-1 ff JU W W MKw 'w W-
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APPLICATION - STREET IMPROVEMENVEXCAVATION OPY TO:
ORDINANCE NO. 74-14 ( • LE
-
(YELLOYELLOW) IN
(INSTRUCTIONS ON SEPARATE SHEET) �` (PINK)-OTHER AGENCY
� (BLUE)-APPLICANT
APPROVED QQ APPLICATION i40.'
NOT APPROVED ❑ CI I l UI' I IG.NRI), OREGON FEE AMT., S -j Z.
PENDING FEE. PMT. ❑ CITY IIIALL RECEI TI SVA,: -III _
PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT BY DATE—,//- I 4-
PENDING
PENDING AGENCY "OK'' ❑ Application and Progress Record
MAINTENANCE BOND
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS HEauIRED
ANNUAL
PENDING VARIANCE ❑ EXPIRATION U TE.
PERMIT NO }17 4 -1 DATE ISSUED: __-��L L I___-- , BY.
(1 ) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL_ Driva-I''Y Apyroach
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY U2I49ft"TS.
APPLICANT Aterson, DIeloren Wayne 11611 SW i,esser Lid. Ptl, CR 97219 #Off ice 248-24.72
NAME - - ADDRESS CITY - PHONE—
CONTRACTOR
NAMF- ADDRESS - CITU ---------' -_--PHONE --
F _ANS B Y __ - - Per City Stan0ards
NAME .r ADDRESS —CITY-
ESTIMATEDIMPROVEMENT TOTAL VALUATION ( COST): $ "•0
DOLL..ARS
-MIN.
(2) EXCAVATION DATA: FOR OFFIC E
_
0.04_X s _ - s 12'00
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE_ LENGTH WIDTH DEPTH ITEM 9, QUANTITY
STREET
i' ND _
72nd AV ue (:; a t: ached R TIO N
Q
U ---
ESTIMATED STREET OPENING DATE:- L i S
ESTIMATED STREET CLOSING DATE: _� _ E — -
---- -- --- - - — --
DI_ -- - - - - STREET
(3) SECURITY NO. ..— SECURITY AMT.: $ __300'00 c.LOSE D
SURETY CO.: FINAL
GHECN_A _�---- CAIH_ 7—SO N D INBPEC.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL- �- SPECIAL PROVISIONS /CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTENT. 1. Notify City inspector
Carl Yieweg (#639-4171)
2. All work shall =iform Lo
1 1 City Standards & Specifications
3. CRS 157.541-.571 applies
�ae-� - _ - - - - - - - - -• - - n - - (Utility Co. prenotification,etc
r---- 7 -----�-- ----- - - --- 4. Traff is control shall be
provided for by contractor
I Sites 240 SW 72nd A .j
-
(5) NOTE 'THE CITY OF TICARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR 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 SAV"S HARMLESS THE CITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS
i
Ar'tL. IC ANTS SIGNA TURF/ 4/11 / ! �/ s ' `
DATE - -f�—
INSPECTION NOTICE
City of Tigard Building Department
P.O. Box 23397
Tigard, Oregon 97223
Phone:1,339-4175
Type of Inspection -.- -�'-L C
Date Requested12 — _— Time--� A.M. P.M.
724-id �
Address/J �__ ` Z = L
! Permit #Zlyk-9—_
Owner _ Lot
Builder .
The following Building Code deficiencies are required to be corrected:
1
v
Presented to YV4 tT-Approved
Inspector L I Disapproved
Date
CALL FOR REINSPECTION
❑ YES ❑ NO
PERMIT TO CONNECT
Tigard Sanitary District
PERMIT N° 1278 DATE
PFR311T IS GIVEN TO
OF
TO CONNECT A ,
TO THE!SYSTEM OF TI�GA�R�D�SANITARY
� DIS,T�RICT
72
THIS PERMIT MUST BE POSTED ON THE DE�7CRIBED PREMISES UNTIL CON-
NECTION IS MADE AND INSPECTION OF CONNECTION HAS BEEN COM-
PLETED. �+
PERMIT FEE PAID $...... ......TIGARD SANITARY DISTRICT
•v By��--+rel:¢=P��f�-V—
- - - ---- --- - - - --
f
CONNECTION INSPECTFL` AND APPROVED
Date- --- - superintendent
t
9
ADDRESS _ J/ �� 410 ` 724 PERMIT N0. La 7J
PERMIT CHARGE _ .�, none _
OUNI-R � '�_ CON14ECTION FEE
PAID BY
TYPE OF BUILDING a %� DATE CONNECTED
INSPECTION FEE
SERVICE RATE z_� -- ._._
b' PAID BY DATE
CONTRACTOR ,.._. --- -------_ —���
SIZE OF CONNECTION ASSESSMENT „�_� _ PAID _