72ND AVENUE & KABLE LANE I
ADDRESS:
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APPLICATION - STREET IMPROVEMENT/EXCAVATION COPY TO:
[X (WHITE)-FILE
ORDINANCE NO. 74-14 ® (YELLOW)-INSP. 1 `
(INSTRUCTIONS ON SEPARATE. SHEET; ® (PINK)-OTHER AGENCYl .
[7{j (BLUE)-APPLICANT
APPROVED W APPLICATION NO.: 418—.—�
NOT APPROVED ❑ (.I I Y OF' 'I IGARD, ORLGON FEC AMT.: E - 60.00
.'ENDING fEE. PMT. ❑ CIlY 1IALL 1 RECEIPT NO.: .--1__ �
PENDING SECURITIE DOTE-�.�� / 1� Z
❑ PUBL IC WORKS DEPARTINENT BY
PENDING AGENCY "OK" 0 Application and ProRTcss Rccord
MAINTENANCE FOND .— _-
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS REOUIRED X
ANNUAL.
PENDING VARIANCE [ 1 IZXPIRATiON DATE. _ OR2 Y,gar
PERMIT NO.: 3Z3-�t�_ _ DA} E ISSUED: ._ / 1"_.lam%C` , BY: --j --
(1)
Y: _-j(1) APPLICATION I S HEREBY MADE TO Raise Ma nhr 1 e9 � ..------to new fill, grade AS DESCRIBED HEREIN, IN FULL ACCORDAN-"E WITH CITY REQUIREMENTS.
APPLICANT H•L.__Green 111 S.W. 5th Suite 2950 PocLIa . UR_' 1,04___ ail-OUlU
NAME ADDRESS CITY PHONE
CONTRACTOR __ (90—M) _ - --
NAME ADDRESS CITY PHONE
PLANS BY -Mackenzie Engineerix4, Inc. 0690 SW Bancroft St. aWtland,. OR 97201 224-9 0
NAME ADDRESS CITY PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ __ 1,500.00
DOLLARS
__ - --- - -- - ------ FOR OFFICE USE: MIN,
(2) EXCAVATION DATA: 0.04 X s 1,.100.00 = a_STREET DESCRIPTION _ PROGRESS & INSPECTION STATUS _
NAME SURFACECUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE�PY
TYPE_ LENGTH WIDTH DEPTH ITEM & QUANTITY _
STREET
PE
Bee att checl Gl in s RN TION
_ E _
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ESTIMATEU STREET OPENING DATE: ..-__�__.. / ES
ESTIMATED STREET CLOSING DATE: / E
(3) SECURITY NO. —.--- SECURITY AMC: $ 500•x
sl, CLOSED.. CLOSD
SURETY CO.: _ __ _ _ FINAL
CERTIFIED CHECK CASH n BOND r INSPEC. _ - _—
A) PLOT PLAN. INDICATE SITE PERTINENT PH 'SICAL —� SPECIAL PROVISIONS/ CONDITIONS:
FEATURES; EXCAVATION LOCATION ANC :XTENT. 1.) Notify City Inspector No.
6j9--4171 (Mr. Mike Mills)
! I Work 3 1 I
_ prior to atartirx� work.
Site X X I , 2.) All work shall000nform to
City and USA Standards
S. W. 72nd AVE. and specifications
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(5) 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 DEFOSIT THE REQUIRED SECURITI_S, TO COP.IPLY WITH ALL PERTINENT '_AWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK, AND T'O SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
APPLICANTS SIGNATURE _� L.w`J �rLC� '" l ' DATE ��.