11550 SW 72ND AVENUE FILE 140. e, STR. OPN PERMIT
72nd Avenue - 11550
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CITY OF T16-ARD
EXPENDITURE REIMBURSEMENT REQUEST 4r
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This form is a multi-use form. Where appropriate receiptL must be attached.
Documentation is important for all purposes. Staple documentation to form.
VENDOR NO: DATF:
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PAYABLE TO: �f )� O )d-Z `7', _, Requested by• /j
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MISCELLANEOUS (parking, books, subscriptions, dues, memberships, etc.) :
Date Description Account No. Amount
l.Fl.�l � 1
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GENERAL MEAL EXPENSE:
-Date Description Amount
Account Number to be charged: _ Total
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M I LI:AGF.
Date Descri tion: (Include end/start readings and total miles) Amount
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Account Number: Total miles x$.21_
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APPROPRIATION BALANCE: _ AS OF: Signature
APPROVALS (if $7'x.00 or under may be reimbursed through petty cash) :
(up to $500.00)Svction Manager +_ _ Purch Agent
($500.01-$5,000.00)Dept. Head/Purch . Agent
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APPLICATION - STREET IMPRC LENT/EXCAVATION COPY TO:
OR DIN,. .,- E NO 74-14 ❑ (WHITE)-FILE
❑ (YELLOW)-INSP.
(INSTRUCTIONS ON SEPARATE SHEET) ❑ (PINK)-OTHER AGENCY
❑ (BLUE)-APPLICANT
APPROVEDl
NCT APPRovED CITY OF TIGARD, OREGON APPLICATION
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FEE AMT.
PENDING FEE. PMT. [f CITY HALL. RECEIPT NO,: 7c^ 7
PENDING SECURITY O PUBLIC WORKS DEPARTMENT By
DATE
PENDING AGENCY "OK" ❑ Application and Progress Record - - - - - - - - -
PENDING INFORMATION LJ FOR STREET IMPROVEMENT/EXCAVATION MAIN s REQNE
UIR BOND
PENDING VARIANCE ❑ ANNUAL
— p _ EXPIRATION DATE:
PERMIT NO. Z EJ DATE ISSUED lF' BY;._ l t _ G �C
— - —---—
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL 4- ' ilCr-
rLLtK:� ryVa,y AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT ___j 0 _ f� —, !il/c 7211r gU ��
NAME AUORElS - _
- 'may, C� PHONE
CONTRACTOR C (j--
PLAN; BN CIT_ „///g
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Clt PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): s __. -r
_,. DOLLAR[ _
(2) EXCAVATION DATA: FOR OFFICE UsE: -
'�`
0.04 X S ^--
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED
TYPE LENGTH WIDTH DEPTH ITE & UANTITY ITEM DATE REMARKS/TYPE BY
Z 7 -3 _ STREET
e'c'� I; ty `e P N
INSP
R TION
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ESTIMATED STREET OPENING DATE: -f/ ES
ESTIMATED STREET CLOSING DATE: / / T ——
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(3) SECURITY NO. _ _- SECURITY AMTS— L STREET
SURE 1-Y CO.: — _ CLOSED
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CEpTI FItD CHtCN n___ c A_SH [OND r INSPEC. ' -
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL _ —� f$
FEATURES, EXCAVATION LOCATION AND,EXTENT. � SPECIAL PROVISIONS/CONDITIONS:
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(5) NOTE THL CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLILANTS TO CONDUCT WORK WHERE
RIGHT-OF-WAV IURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON
THE APPLICANT AGREES TO DEF`OSIT 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 WHICI-LMAV RESULT FROM APPLICANTS ACTIONS
APPLICANTS SIGNATURE
DATE
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