14825 SW 81ST AVENUE FILE NO. _e)2.
81ST AVE. - 14825 srrR. OPN. PERMIT
APPLICATION — STREET IMPRr cMENT/EXCAVATION COPY TO:
ORDIN—ACE NO. 74-14 r� (BLUE) INSPE
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APPROVED Lit APPLICATION NO,:
NOT APPROVED El CITY OF TIGARD, OREGON FEE AMT.: s 4
PENDING FEE. PMT. L1 CITY HALL RECEIPT NO.: . ILLI fV
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PENDING SECURITY ElPUBLIC WORKS DEPARTMENT BY JY DATE
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PENDING AGENCY ❑ Application and Progress Record
MAINTENANCE SONO �k
PENDING INFORMATION ElFOR STREET IMPROVEMENT/EXCAVATION AS REVUIRLU
ANNUAL.
PENDING VARIANCE L7 EXPIRATION DATE: .
PERNi!T NO.: -� �--- �_1 -- ------. DATE ISSUED: _ "Z_(1_Q? BY: `r
(1) APPL.ICA ION IS HEREBY MADE TO EXCAVATE FOR AND IN-,STALL .__-LJ?11c re.', e_TjK.�
AS DESLRIBED HEREIN, IN FUD... ACCU�IDANCE WITH CITY REQUIREMENTS.
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APPLICANT ._. (�i•1:)r /c.5 �� l��iG�, ��8/ � G3 /—444
//NAME ADDRESS CI �LrR�Fi01-4E
CO1h1-RACTOR (rr2
NAME // ADDRESS -�-- -----------___._-'--� GIT PHONE
PLANS BY___-_� �'I� S.ltEf-th
NAME ADDRESS-_----- --__ -�--- CITY PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $
DOLLARS
FOOFFICE US[: ( MIN.
(2) EXCAVATION DATA: !) 4x$--
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE_ REMARKS/TYPE BY
TYPO LENGTH WIDTH DEPTH ITEM & QUANTITY
STREET
OPENED _
INSPEC-
R TION
17
ESTIMATED STREET OPENING DATE: / E
ESTIMATED ST---EET CLOSING DATE: , --/"f7 / Z E
ST-REET
(3) SECURITY NO. — SECURITY AMT.: $ CLOSE
SURETY CO.: _ _ FINAL
C[R7IFIEU CNFCK ❑ --�CAS11 1:1 BONN r? INSPEC.
14) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL, SPECIAL PROVISIONS/CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTENT
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(5) NOTE. THE CITY OF TIGARD DOES NOT, HEREBY. GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WYERF
RIGHT-OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATI: OF OREGON
THE APPLICANT AGREES TO DEPOSIT THF REOI_IIRED SECURITIES, TO COMPLY WITH ALL PERTINENT LAWS AN11
CONSITRUCTIO►4 SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY ANTI
EMf LOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS
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APPLICANTS SIGNATURE: 2
DATE
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