10387 SW 87TH AVENUE FILE NO.
87TH AVE. - 10387 STR. OPN. PERMIT
CITY")F TIIFAPD
EXPENDITURE RrIHBURSEMENT REQUEST
This form is a multi-use form. Where appropriate receipts must be attached.
Documentation is important for all purposes. Staple documentation to fotm. \
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VENDOR N0: AATa: Z -?Z-`s
PAYABLE TO: $r�v% UCi?y011 Requested by: __ _ -----
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AISI:ELLANEOUS (parking, books, subsc-.i:ptions, dues, memberships,
Date _Description Account No. Amount
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GENERAL MEAL EXPENSE:
-Date Description Amount
Account Number to be charged: - Total _
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hILEAGE
Dhte Description: (Include end/start readings and total miles) Amount
Account Number: Total miles x$•71
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AP11l,tPRIA11ON BALANCE: AS OF: Signature-
APPROVALS (if $25.00 or under may be reimbursed through petty cash) :
(up to $500.00)Section Manager _ Purch. Agent
(:500.01-$5,000.00)Dept. Head/Porch. Agent_
C ITY OF TI ARD No- 28862
13125 S.W. HALL BLVD.
P.O. BOX 23397 (y
TIGARD,OR 97223 Date_ Q
1 ) I
Name ��/
I.UZ S r �
` 1 Address
IAOV- b Lot Block/Map Su dl Islon/Address
�.� \
�V\e,,�o Permit #i's Bldg. Plumb Cash C _c-k
Sewer
Other Other Re,� --
Acct. No. tiscrlption --
10.432Amo
Buildin Permit Fees
10.431.600 Plumbing Permit Fees —--
10.431.601 Mechanical Permit Fees
10.230.501 State Bid . Tax
10-433 Plans Check Fee--- -
30.443 Sewer Connection ---
30.444 Sewer Ins action --
51.448 Street S st. Dev. Charge —
52.449.610 Parks I Sy4t. Dev, Charge
52.449.620 Parks 11 Sy!tt. Dev. Charge
31-450 _ Storm Drainage Syst. Dev. Charge
10.4:,0 Business Tax
10.434 Alarm Permit
10.227 Bail
10-455- Fines - Trafflc,T"'d/Parking
10-230. _ CFrA T f !If car MisdlVlc. Asst .
10-456 Indigent Defense -
30.122.401 Sewer Service/USA
30-122402 Sewer ServlcelClty 30%
30.123 ewer Sevlce/Clty Malnt. -
30-125 Unmatched
1.124 Storm Drainage-
-475 ancroft Prin. Pymt.
4U 471 ancroft nt.Pymt.
TOTAL ?
ACCOUNTING COPY
PLEASTAKE Ty T_ TO THE CASHIER FOR A RECEIPT
NAME 7 /i' �' 'j/ - DATE:
ACCT. # DESCRIPTION AMOUNT
C10-22000 �'� Refundable Performance Rond D_posit $_
10-•43500Sign Permits HOP TU $
10-43600 Public Sewer Plan Check Inspection Fee $
10-43.600 Public Storm Plan Check/Infection Fee $
10-43600 _^ Street Dedication/Public Improveme•1t Fee $i
10-43600 +, ' Street Opening Permit �_ $
10-43601 Street and Traffic Marking $
21-44200 Street Light Fee $
10--43700 Subdivision Applications:
S MLP S
10-43800 Zoning Application- :
ZC CPA !OA PD Misc
SCE CU SLP V $ __
10-44000 Other Planning Fees:
SDR
Nor, refundable portion of Appeal Fees
10-22000Refundable portion of A;:aeal Fees $ _
10-45100 Document Sales:
Engram Planping Bldg.
10-43000 Business Tax _ S
TOTAL
1O45P/0O23P
70-
519
0-o
�s
ale
loo
o�
l ! +*
APPLICATION -- STREET IMPR' cMENT/EXCAVATION COPY TO:
ORDINr..aCE NO 74-14 El (WHITE)-FILE
❑ (YELLOW)-INSP.
(INSTRUCTIONS ON SEPARATE SHEET) ❑ (PINK)-OTHER AGENCY
❑ (BLUE)-�APPLICANT
APPROVED APPLICATION NO.:
NOT APPROVED APPROVED ❑ CITY OF TIGARU' OREGON � `"=-
FEE AMT. Y e, _-
PENDING FEE PMT. ❑ CITY HALL RECEIPT NO.:
PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT BY_/LZ 1 i DATE /?71f-7
PENDING AGENCY "OK" ❑ Application and Progress Record ..
MAINTENANCE BOND AI�_
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS REQUIRED
ANNUAL L;O
PENDING VARIANCE EXPIRATION DATE:
PERMIT NO.' Z7� DATE ISSUED: -7�
BY: -7
L 1-- -- . - ---
(1) AP-PLLI•-CATION IS HEREBY MADE 10 EXCAVATE FOR AND INSTALL
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT �!_. 1N ME5� �– A o�,
CITU PHONE
ertYd
/ /
CONTRACTOR�(�/';"�'r AMljn/� i'D�l - '�.'1 0en / - �1 _..___l2 rZ' C/-<?
" CITY PHONE
PLANS B" 'e- S -�'r �
NAME a DD ESS CITY _---- --- -PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST: s — �
DOLLARS
(2) EXCAVATION OFFICkjfS�E_U_=C u I[ MIN.
EXCAVATIUN DATA. _ 0.04 X = 7 ' i _
STREET
STREET DESCRIPTIONPROGRESS & INSPECTION STATUS
NAME SURFACE CUT ECul' CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LNGTH WIDTH DEPTH ITEM Q QUANTITY
STREET
F N D 7,fY {lft/AGT"
INSPEC-
R TION
E
Q
U
ESTIMATED STREET OPENING DATE:��_ / 17L E
S
ESTIMATED STREET(.:LOSING DATE
D _
L� � STREET
(3) SECURITY NO. _ _ SECURITY AMT.: $ _-- LLOSED
SURETY CO : FINAL
CERT-IFIE11 CHEZ-K - - .. .._CASH SONO 6 INSPEC.
-_ t-+s- -
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS:
FEATURES: EXCAVATION LOCATION AND EXT�NT.
1 I � gpr_ S
AP I
144,1 1
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I I I I I
(5) NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT P'-RMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT OF•WAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF' OREGON.
THE APPLICANT AGREES TO REPOS-T 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 WHICH MAY RESULT FROM AP*LICANTS ACTIONS
:ooxl
APPLICANTS SIGNATURE DATE