11767 SW 91ST AVENUE-1 ids
N
FILE NO. 30 Efcf}
91ST AVENUE - 11767 STR. OPN. PERMIT
APPI.ICATION -- STREET IMPP FMENT/EKCAVATION COPY TO:
ORDINANCE NO 74-1,' L (WHITE,-FILE
❑ (YELLOW)-INSP.
(INSTRUCTIONS ON SEPARATE SHEET( Cl (PINK)-OTHER AGENC-
❑ (BLUE)-APPLICANT
APPROVED L7 APPLICATION NO.- � 7
NOT APPROVED �, CITN' OF TIGARD,OREGON eno
FEE AMT.. f _
PENDING FEE PMT. ❑ CITV HALL RECEIPT� : A�79
PENDING SECURITN PUBLICWORKS DEPARTMENT BY`�
.. DATE /=2
PENDING AGENCY GK- L ppllcation.nd MroKTcss Record — — — —
MAINTENANCE BOND M
PENDING INFORMATION ❑ FOR STREET IPAPROVEMENT/EXCAVATION Ate. RcoUIRCD L
✓
PENDING V ANNUAL'VARIANCE ❑ p EXPIRATION DATE:
PERNII T NO.: 314 P DATE ISSUED � BY:
(1),APPI_ICATIt7N IS HEREBY�MADE TO EXCAVATE FOR AND INSTAL!_ y<<1 �* C_c(,'C' '
d- -' - -'- 'lffL--024S DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY R 'W!-��E ITS.
APPLICANT �r'!s�'1llSSEt.I (bbtp S.v, �p�1�S�F� 'j�6*yto G,1* (,1loyzO�aCCS39Zc23 A NH
E AODRE _- CITE--� �I PHONE
' ONTRACTOR ;;-_ � Lv14SIT 1pC�Zo�IJ 3C)AgwgF cmc (o2SS
A E ADDRESS
—C PLANS BY BY lE
NAM! ADDRESS ------' - ---- -
/ CITY
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S : 50. yo
DOLLARS
(2) EXCAVATION DATA: FOR oFFICE,usE;
0.04 Xf _ --
STREET aL DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALL.ID
TYPE LENGTH WIDTH DEPTH ITEM A QUANTITY ITEM DATE REMARKS/TYPE BY
S 5NAtT ?p e 1 I el�yPJs>
TR EN IION
r1
ESTIMATED STREET OPENING DATE:- Z-" / +C / CF S
ESTIMATED STRE,%T CLOSII-IG DATE: / / T
(3) SECURITY NO. 5ECUR1?'' AMT.: E (G S � STREET
CLOSED
SURETY CO.: _ tit FINAL ,
�^ CERTIFIED CMEt_1t -�,..-�' p INSPEC. - - -
(4) PLOT PLAN. INDICATE SITE PERTINENT PHYSICAL •� SPECIAL PROVISIONS J CONDITIONS
FEATURES; EXCAVATION LOCATION / D EXTENT.
(URS - - - - - .♦ I - - -' 1� - -
�p�
�L��
1 //776 - r I 1
Ise NOTE THE CITY OF TIGARD DOES N')T, HEREBY. GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT-OF-WAY JURISDICTION IS THA r OF WASHINGTON COUNTY OR THE STATE OF OREGJN,
THE APPLICANT AGREES TO DErOSIT THE REQUIRED SECURITIES, TO COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THF WORK, AND TO SAVE HARMLESS TRE CITY ,AND
EMPLOYEES AGAINST ANY INJURY CR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS
APPLICANTSSIGNATURE / �W"`'�./_ � �' �' �'
OATS
CITYOFTi. IRD No.
3795 ,
13125 S.W. HALL BLVD
A P O. BOX 25397
TIGARD, OR 97223 Date
Name
Address _
Lot Block/Map Subdivlsl-mlAddress ----
Permit ft's Bldg. Plumb
Cash Check
Sewer Other
Other Rec. By
FAct. No. _moun�
DescriptionA32 Bulldin Permit Fees
10.431.600 Plumbin Permit Fees --
10.431-601 Mechanical Permit Fees
i0.230-501 State Idg. Tax
10.433 Plans Check Fee
30.443 Sewr r Connection _
30.4— 4—4 Sewer lnspection -- ---
51-448 Street Syst. Dev. Char e
52.449.610 Parks I Syst. Dev. Charge —
52.449.620 Parks II Syst. Dev. Char _ge
31.450 Storm Drainage Syst. Dev. Charge
10.430 Business Tax --
10.434 Alarm Permit -
10-227 Bail —
10.455 Fines • Traific/Misd/P r na ik g
10-230- CPTA TraffIC/Misd/WC.Asst
10.456 Indi®ent Defense _
30.122.401 SewerSe
' 30.122.402 Sewer it,erviC.s/City 30°6
30-1 Sewtr Sevice City aint.
0.1 5 - Unmatched —— -
31.124 Storm r�inagt
Bancroft 1'r1n. ymt. '--
0.471 _ ancroft Ini. ymt. --
-- ---- —... TOTAL -
C)
s
KENNETH A. RASMUSSEN
DARLA RASMUSSEN F-�l 19 tie, 102
10010 SW JOHNSON 620-5323
TIGARD, OR 87223 24-12/419
1230
Pay to the
Order
�1.1�C��.t.v..L1ni��, Dut,�..4��2titi O•c I �./r, . I
�� FAN FIra1 Inlenula Bank 513 001 0473774 8001
of Or*Inf et N A.
kf�ly>st ilpard Branch NOT VALID FOR LESS THAN $100
Bank P .Bo.232 f a
ilparl.Orapen 21223
For ,
(��:7 s llsr Erx� ria,,,.,,
t(. INS1'frikir
1: L 2 3000 L 2 31:7 l 2 06 700 l 41Ie 102
CITYC MAIM
EXPENDITURE REIMBURSEMENT REQUEST 1
This form is a multi-use form. Where appropriate receipts must be attached.
D-,cumentation is important for all purposes. Staple documentation L, form.
VENDOR NO: — _a- DATE:
PAYABLE TO: Y__(?-hhr4 ^, 1. � .rt,uS r�1 Requested by:
c1 -7 Z 7-
---------------------
MISCELLANEOUS
-¢e:yeas-vers----ev.creceMISCELLANEOUS (parkinZ., books, subscriptions, dues, memberships, etc.) :
Date . Description, Account No. Amount
10 - Z Z.c•
o
dzlccl IZ Zl Yy°,
er_¢¢cr_ee e+----- ------reed=ccr_aar.cese¢ececr_eeeee ccice c=ccczcc:c.zccccccc r_zaccz=ca cear_
GENERAL MEAL EXPENSE:
-Date Description - Amovtnt -
Account Number to be charged: -� Total _
eacr-ec^ae¢¢�¢e.-=sce•sc-_terse-enercae�cecs=e�¢cac...ceccecc-ecus=c.�=caccxcec=�ca-�
M I LEA('E:
Date Description: (Include end/start readings and total miles) Amount
1 Account Number: Totei milt-^ �:�.21
saessasmeeesee■eire:rr.■¢t■■■■■■ar_e:ecer r_s_v=.-cesav:encecaca r.acceer_cr_¢,-aar-_meati^.cc■■ ■ � .` ' ���C��4
APPROPRIATION BA!.ANCE: - - -_AS OF; - � Signature-
APPROVALS (if $25.00 or under may be reimbursed petty through ca-h) :
p y ca h) :
(up to $500.00)Section Manager _ Purch. Agent
($500.01-$5,000.00)0ept. Head/Pirch. Agent
wECEIVEp
Har ch 1989
MSIR 2 9 1989
CITY OF TIGARb
c/c Public Works
13125 S.W. Hall Blvd.
Tigard , OR 9'7223
Attn: Mr . Mike M IIs
RE: 11767 S.W. 91st Street Patch
Dear Mr . Mills:
Per our telephone conversr.tion March 29, 1989, your in6pection of the
ahove referenced project was approved on this date.
Please release the bond ( Deposit Slip #32795) and mail to :
Ken Rasmussen
10010 S.W. Johnsor,
Tigard , OR 97/223
Thank you for your cooperation, and it has been a pleasure working
with you.
Sincerely ,
Ken Rasmussen, P.F .
k'r�/sk
r �
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