11449 SW PACIFIC HIGHWAY 11449 PACIFIC HIGHWAY
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INSPECTION NOTICE
City of Tigard Building Department
P.O Box 23397
Tigard, Oregon 97223
1�f Phone: 639-4175
Type of Inspection -
Date Requested _ Time A.M. p,M,
Address _�,�/ i V�
- #1Lz1 _
Owner
/
Lot #
BuilderThe following Building Code defirienries are required to be corrected:
Presented to _ i _.
--- Approved
Inspector LZ77
� � Disapproved
Date.
CALL FOR REINSPECTION
0 YES C7 Np
I
APPLICATION - STREET IMPROVEMENT/EXCAVATION { COPY TO:
(WHITE)•F11 a
ORDINANCE NO. 74-14 (YELLOW)-, SP.
���, �'� `• (PINK)-OTHER ACIRN YBld,
(INSTRUCTIONS ON SEPARATE SHEET) 1 ' (BLUE)-APPLICANT
APPROVED }• APPLICATION NO.:
NU'f APPROVED
(.I I Y OH l IGARD, OREGON FEE AMT.: S—
PENDING FEE PMT. [] CITY IIAI.I, RECEIPT NO.: oO103745
PENDING SECURITY ❑ PUBLICWORKS DEPARTMENT BY ._.,14ii _ w DATE _ 51 L{ I,l't
PENDING AGENCY "OK" n Application and ProRTess Record MAINTENANCE BOND N ---
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS HFLJUIRED c
ANNUAL. Li
PENDING VARIANCE i�
EXPIRATION DATE. one Y'�IaC
EXPIRATION
PERMIT IJO. DATE ISSUED: BY. -- --- ------------
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTAL(_ t�'1�i�r�y A•�• �irly�"<Y;i vl�rcn)
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT
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CITU PHO
CONTRACTOR _ unmown
ME ADbR ESS - CITY PHONE
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PLANS BY _ --- ---- CITv ------ --THONE—`—
NAME -- ------- ADDRESS
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST(: ; --
DOLLARS
FOR oKFICK USE:
(2) EXCAVATION DATA. 0.011 xf •.') _= f�'•-�
STREET _DESCRIPTION _ PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WID'rH DEPTH ITEM AI QUANTITY
STREET
OPENLI2
-- —" - — - INSPEC-
R TION -_
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ESTIMATED STREET OPENING DATE:- ) _ S
ESTIMATED S 1 REET CLOSING DATE: _— �� I '' TIE �—
D
STREET
(3) SECURITY NO. -- SECURITY AMT: $___` CLOSED
SURETY CO.: _----- -__ FINAL
CERTIFIED CHECK CASH sONQ iNSPEC.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL T--�= SPECIAL PROVISIONS / CONDITIONS
FEATURES; EXCAVATION LOCATION AND EXTENT. L. All b
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A200 SW Rose St.
(S) NOTE: THE CITt OF TIGARD DOES NOT, HERESY. GRANT PiEFIMISSION TO APFLICANTS TO CONDUCT WORK WHERE
RIGHT-OF-WAV JURISDICTION IS THAT OF WASHINGTON COU14TY OR THE STATE OF OREGON.
THE APPLICANT AGREES TO DEPOSIT T14L REQUIRED SECURITIES. TO COMPLY WITH ALL PERTINENT LAWS AIJD
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY AND
Eti1PLOYEFS AGAINST ANY INJURY OR DAMAGE WHICH MAY REVULT FROM APPLICANTS ACTIONS.
APPLICANTS SIGNATURE DATE