12300 SW DUCHILLY COURT-1 FILE ;o. 22 g- j STR. OPN. PERMIT
—' DUCHILLY CT. - 12300
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GI" `OF TIGARD
EXPENDITURE RU MBURSEKENT REQUEST
This form +s a multi-use form. Where appropriate receipts most be attached.
Documentation is important for all purposes. Staple documentation to form.
VENDOR NO: DATE: — 1_y-- v--, k�
PAYABLE TO: �cAAv ' PeQuested by:
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MISCELLANEOUS (parking, books, subscriptions, dues, memberships, etc. ) :
Date 1, Description _Account No.
�Am�ount
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GENERAL MEAL EXPENSE:
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at e Description Amount
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MILEAGE:
Date Description: (Include end/start readings and total miles) Amount
Pccount Number: _ _ Total miles .20 w
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APPROPRIATION BALANCE: VAS OF: Signature____.___--_______
APPROVALS ( if :75.00 or under may be reimbursed through petty cash) :
(up to $500.00)Section Manage: Purch. Agent
( 15OU.01-15,000.00)Dept . Head/Put -h. Agent
BMXX] Omp�1 Qavixlty, OregoZt
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Pd-57A& By :
CITY OF TIGARD No 10195
12755 S.W ASH
P.0 BOX 23397
TIGARD,OR 97223
Name
-4 ddron-5
Lot cxc1%4�a SubdivisionlAddress
- rj1p( k
Permit N' dg.
Other
Acct. No. Descripli-,-
VY43? Building
_Etrrpit Fees
/0431600 Plumbing Permit Fees
10 431 601 Mechanical Permit Fees-
10230501 State Bldg.-Tax
10 413 Plans Check Fee
30 443 Sewer Connection
30 444 Sewer Inspection
.)1-448
Street Syst. Dev. Charge
--52-449:6TO Parks I Syst. Dev. Charge____
52-449620 Parks 11 Syst.-Dev_-
31-45-6- Storm Drainage Syst Opy. Charge
10-43(1 Business Tax
-0-�34 -Wi-arm Permit
Bail
10-455- Fines -7raffi(-1MisdiF,0,;
10-230- C13TATraffic/Miscl/Vic A-,,,I
10-456 Indigent Defense
30-1 22 0 1 Sewer E)orvlco1LJSA
-79-ew—or S 6—ry I I If it 30 No
36 ce y
j�12J ---gewor Sevice/Cily MilnL
30-125 nmatc ed
—1i—124 Storm Drainage _
—4-0:4-7.5------Ui6crot rin.
DEPT.
/PLEASE TAKE THIS 1.0/THE CASHIER FOR A RECEIPT
NAME: S eel rhe.j0-1a � i1� ZZf��'G .. nATE —�-_ '-z =7
ACCT.
_ DESCRIPTION SUNT
10-220 Refundable Performance Bond Deposit -_ _ S 4 1 _
10-435 Sign Permits HOP _TU
10-436 Public Sewer Plan Check/Inspection Fee -
10-436 Public Storm Plan Check/Inspection Fee_-
10-436 Street Dedicatiori/Public Improvement Fee
:0-436 Street Opening Permit
10-437 Subdivision Applications:
S MLP
10-440 toning Applications:
ZC CPA ZOA PD SDR Misc
-- SCE — CU _ SLP -- - -- -- _ --
21-442 Street Light Fee
10-451 Document Sales:
Engrg. Plannin3 Bldg_ S
10-451 _ Street and Traffic Signer
TOTAL
(1045P)
f
APPLICATION - STREET IMPF 'EMENT/EXCAVATION COPY TO:
ORDIN. ,NCE NO 74-14 (WHITE)-FILE
(YELLOW)-INSP.
(INSTRUCTIONS ON :;CPARATE SHEET) 6U� NK)-OTHER AGE
>a (BILUE)APPL CANTNCV
,
APPROVED APPLICATION NO ZS
NOT APPROVED U Cl I Y O TIGARD, OREGON FEL AMT.. S . __ � 7
PENDING FEE. PMT. ❑ CITY HAL'. RECEIP
PENDING SECURITY 13 PUBLIC WORKS DEPARTMENT 13Y _ �. DATE ' L27/�
PENDING, AGENCY ''OK'' ❑ 1pplication and Progress Record — — — — — — — — — — — — — —
FOR STREET IMPROVEMENT/EXCAVATION MAINSEEQUREBON Ir
PENDING INFORMATION ❑ 71c� `----
ANNUAL
PENDING VARI'.NCE ;_� EXPIRATION Df TE
PERMIT NO DATE ISSUED
( 1 ) AnPPL.ICATIQN IS HEREBY MADE TO EXCAVATE VOR AND INSTALL - ✓L>a;-s 2yc Jc s 78
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITO CIT" REQUIREMENTS.
APPLICANT _ NAME 1.
1/ r P
CONTRACTOR
PLANS BY
NAME i ADORES[ CIT T --F OF411
ESTIMATED IMPROVEMENT FOTAL VALUATION ( COST): :
DOLLARS—_ 9 B,qH �� • << 10.11
- - 7
FOR OFFICE U E: CMIN�)
(2) EXCAVATION DATA
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM & QUANTITY
—T STREET
/f•a1 C c _ _ PEN D
INS C-
R TION
E '—
Q
ESTIMA fED STREET OPENING DATE:_��7Y / ZC` s E
S
ESTIMATED STREET CLOSING DATE: T --
F-
(3) SECURITY NO. ECURITYAMT.: s�'f STREET — -
9HRtTT-Cp _ ..I o__ n c k huN C FINAL CLOSED
CHECK' ---- LL CASH O MOND i INSPEC. _
(4) PLOT PLAN' INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISION3 /CONDITIONS:
FFATUVS; EXCAVATION LOCATION AND EXTENT.
I ,
63l 41-1
I I I I
1 I I I
(S) NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMIgSIOw TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT OF WAY JURISDICTION IS THAT OF WAS14INGTON 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 I or, WORK, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINST ANY JURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
i
APPLICANTS SIGNATURE tti / �`�
• DATE--
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