11767 SW 91ST AVENUE-3 9
FILE NO. 3I'd:f�fr'
91ST AVENUE - 1.1767 STR. OPN. PERMIT
APPLICATION — STREET IMPP c7MENT/EXCAVATION COPY TO:
ORDINANCE NO. 74-14 ❑ (WHITE)-FILE
❑ (YELLOW) -INSP.
(INSTRUCTIONS ON SEPARATE SHEET) ❑ (PINK)-OTHER AGENCY
❑
(BLUE)-APPLICANT
APPROVED (ate APPLICATION NO.: 3� 0
NOT APPROVED [] CITY OF TIGARD, OREGON FEE AMT. i -;.6 .00
PENDING FEE.PMT. ❑ CITY HALL RECEIPT O.
PENDING SECURITY ❑ PUBL)CWORKS DEPARTMENT SY�'�,J DATE--Al JE!9I`/43_
PENDING AGENCY "OK" ❑ Application and Progress Record — — — — — — —
MAINTENANCE BOND N
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS REQUIRED —�—
PENDING VARIANCE ❑� ANNUAL L
EXPIRATION DATE: ��
PERMIT NO.: 3t4 — ISS DATE ISSUED: �lz`- BY:
(1),APPLICAATION IS HEREBY MADE TO EXCAVATE FOR AND INSTAL)_
.S I{'-Z. �l-� ' �PS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY RUp�1REV5N
APPLICANT -� 1` A�MUSSC`7.I (OOIo S.v, �oHrlSalJ bl? r-1
NAME AUORESS _;` CITY _ �� MHO [ ��
CONTRACTOR )E lFhfl� Co��L IDoZ�Shu SDtIIrSLN-� G -(c SSS
NAME ADDRESf — CITU---'---- �jjONF
PLANS BY ��►"'IE _
NAMH ADDRESS
CITY HpNEESTIMATED Ilh -?OVEMENT TOTAL VALUATION ( COST): $
DOLLARS
II) EXCAVATION DATA: FOR oFFICE SIL, --7 cMIN.
0.04 X ! r" S( ` `' _ _ ��
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLS D
�fyTYPE LENGTH WIDTH DEpPTH ITEM & QUANTITY ITEM DATE REMARKS/TYPE BY
S 't'A�LT ZD ?1 11 N APJS _ STREET
r P NC"D
C, l L /7n t? Y/ � R TION
EC�u-
ESTIMATED STREET OPENING DATE:
S
ESTIMATED STREET CLOSING DATE:�2" /y(._ / TE
D
(3) SECURITY NO, SECURITY AMT.: $ (E��' CLOSED
SURETY CO.: .._ i+ _ FINAL
- CE_RtI FIEU CHICK �'I _.CASM-Q,.
80140 INSPEC.
(4) PLOT PLAN. INDIC/'.TE SITE PERTINENT PHYSICAL —� � T SPECIAL PROVISIONS/CONDITIONS
FEATURES; EXCAVATION LOCATION AND EXTENT.
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- .
IRS
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5) NOTE THE CITY OF TIGARD DOES NOT. 'IEREBY, GRANT PERMISSION TO APPLICAN.S TO CONDUCT WORK W/IERE
RIGHT-OF-WAY JURISDICTION IS THAT OF WASHIN,TON COUNTY OR 1HE STATE OF OREGON
THE APPLICANT AGREES TO DEPOSIT 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 APPLICANTS ACTIONS
�- 1 -)
APPLICANTSSIGNATURE � OAT[
�� �
CITYOFTI. 4R(0 NO. 32795
131.5 S.W. HALL BLVD
P.O. BOX 23397
TIGARD, OR 97223 Date
Name y --
Address _
Lot Block/Map Subdivision/Address
Permit K's Bldg. Plumb
Cash Check
Sewer Otherr
Other Rec. By
acct. No.
Description Amor
10432 Buildin Permit Fees nt
�10-431.600 Plumbin _Permit Fees �-
10.431.601 Mechanical Permit Fees
10.230.501 State 510 9, Tax
10.433 Plans Check Fee - -
30.443 Sewer Connection
30.444 Sewer Inspection --
51-448 Street Syst. Dev. Charge --
52.449.610 Parks I Syst. Dev. Charge
52.449.620 Parks II Syst. Dev. Charge
31.450 Storm Drainage Syst. Dev. Charoe
10-430 Business Tax
10.434 Alarm Permit -
10.227 Ball -- ----_ _
10,455,
Mis
Fines -Traffic/ d/Parks+g -
10.230- _ CPTA Traffic/Misd/Vic. Asst.
10.456 Indigent Defense
30.122.401 Sewer Service/USA --
30.122.402 Sewer ServfcelCfty 30%
0.123 Sewer SevlcelCity Maint. -"
3 -125_ Unmatched d
1.124 torm Drainage ' -
0'47 , ancro t Prin. 111111vIt.
40.4 - ancro t Int. ymt.
� —�.____� �-•� TOTALf
fit. 0
KENNETH A. RASMUSSEN
DARLA RASMU'.iSEN r ( `l lgb3-` 102
1U010 SW JOHNSON 620-5323
TIOAP:o, OR 97223 24-12/419
1230
Pay to the
Order of ( C1 1
�t Flrsl Interstate Bank 513 001 0473774 8001
of Oregon,N A.
�M Tlparrr Branch NOT VALID FOP. LESS THAN SIU0
P.0.4.')a 23218
Tlpa ,Oregon gIt2J
L f`
For I ISL-7 S t
cS"- �I �• X.` �'f lN�� i ! v1 r'1���?`- <<dr)r •. . . 1
C—G 11451'(:(k N
I: L 2 3000 L 2 3i:o L 2 C F, '00 1 411, LO 2
CITYC TKARD
EXPENDITURE REIMBURSEMENT REQUEST
tix.sn. _ 1
This form is a multi—use form. Where appropriate receipts must be attached.
Documentation is important for all purposes. Staple documentation to form.
VENDOR NO: _ DATE: - I — <_19
.
PAYABLE T0: _ �Ph
>1C�,LAZ1 uS�C_61 Requested by:
tG`Otu' ; hsc
`L,.r , `i 7 Z 7-'S
GC<�GaC��QGGGGGGGGaGGGCLCIIIIGGCGGGC�SC=�=IIGGCIILCCCC==�CTfC�'CGC2�=�G��CCC�CCCII�Gt
MISCELLANEOUS (parking, books, subs,:riptions, dues. memberships, etc. ) :
Date Description Account No. Amount
V_
1L ZZ.c_'
ZZ795
GGrIIeeaarsGGeaaae-ccGGe ------- Gt-a<r_ce GGGLCGcc::=:ct=LIIacr_GGa_e Gee`.r.Gcsx r_cc r_x.ccIIc
GENERAL MEAL EXPENSE:
-bate Description Amount
Account: Number to be charred: _ To; :al
car_II-eesaGG ev<-=:rG=GGeecr- -=Q�G«Gr^G=c-eGII^a==r_====eeeGGr.Ge a_Gr.Gaeac GGCGII::<s==;-
MILEAGE:
Date Description: (Include end/start readings and total miles) Amount
out
I Account Number: _ Total _ .a;les
APPROPRIATION BALANCE:
-_AS OF: �- Signature t ;;
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/Purch. Agent
i
ALCEIVEC March 29, 1989
MAR 29 1989
CITY OF TIGARD
C/o Public Works
13125 S.W. Hall Blvd .
Tigard . Or 97223
Attn: Mr . Mike Mills
RE: 11767 S.W. 91st Street Patch
Dear Mr . Mills:
Per our telephone conversation MP.rch 29. 1989, your inspection of the
above referFnced project was approved on this date.
Please release the bond ( Deposit Slip #32795) and mail to :
Ken Rasmussen
10010 S.W. Johnson
Tigard, OR 97223
Thank you for your cooperation, and it has been a pleasure working
with you.
Sincerely,
ken HasIriussen,
KR/sk