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MARCH 30 19 92
77h AVE. 11535 STR. OPN. PERMIT
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City of Tigard
INSPECTION REQUEST
I for
I INSPECTION TIME: ���� sCr� PERMIT NO.:
DATE: DATE ISSUED:-
OWNERS NAME :
ADDRESS :
I
CONTRACTOR :. -�-� �' • � �
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TEST* Air 0, Water [? , Visual Laboratory p
I RESULT: Approved Disapproved p Pending [—j
SKETCH: �
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I INSPECTOR DATE
COTE : Attach supplemental test clots hereto]
TJNITLID P( _0IFIC INSURANC ; C0MJ='ANY
HOME OFFICE, TACOMA, WASHINGTON
LICENSE OR PERMIT BOND
Bond No. U 952886
KNOW ALL MEN BY THESE PRESENTS:
That we, _____GOR_DON D. CARPEI\ 'ER
as Principal, and UNITED PACIFIC INSURANCE COMPANY, a corporation organized under the laws of the State
of Washington having its principal office in the city of Tacoma,Washington, and authorized to transact the busi-
ness of Surety in the State of_�rexotlas Surety, are held and firmly bound unto` —
as Obligee,in penal sum of
FIVE HUNDRED AND NO/100ths - - - - - - - - - - 500.00
--
_ _____..._---------..._-__-- -____) Dollars,
!awful money of the United States, for which payment, well and truly to be made, we bind ourselves, our heirs,
executors, administrators, successors and assigns,jointly and severally, firmly, by these presents.
WHEREAS, the said Principal has applied to said Obligee for a license or permit
RiF;ht of Wey,_ .P_ermit__in cQnne D � it e.-. 74���4,_and__#7_6._1.L_—... - - --- - ----
NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH, That if the said Principal shall in-
demnify said Obligee against all loss t it caused by said Principal's breach of any ordinance, rule or regulation
relating thereto, then the above obligation shall be void, otherwise to be and remain in full force and effect.
PROVIDE", THE LIABILITY OF THE SURETY upon this bond shall be and remain in full force and effect for
thefull period of the certificate, license, or permit issued to the Principal above named but not beyond
July 13, ____ 1977_, or ten days after receipt bythe Obligee of awritten notice signed
by such Surety,or its authorized agent, stating that the liability of such Surety is thereby terminated and canceled.
Provided further, that nothing herein shall affect any rights or liabilities which shall have accrued underthis bond
prior to the date of such termination.
This bond may be extended for a further term by the issuance of a Continuation Certificate signed by the Surety.
Dated July 13 76
_- 1;ORDON D GRPEt*TE
PRINCIPAL
UNITED45A-6IFIC ISVRANCYOM
-- -
BDU 7;301 ED.7.71 By • '�' .�/_ r✓ `�
ILlempATTO Nt r•IM•K Ae
(TI-YOFTIGARD ( CITY OF TIGARD
A $
Date Amount �O Date mount
dollars
- Cash
ash
Name
/ Check
Address Address S--3 3 J. 3 ;L 3 Check
-
Bldg. [:] St.Opng, Bus.Lie. Ll Bldg. 1.Opng, Bus.Lie.
P16g. 0 Pubctns. Me Lie. U V169. Pubc1ns. Bike Lie.
f1c11. 0 Copies Sew.5Ie,v. f1,11. Copies Sew.Serv.
Sewer E] Filing Fine&F. S,�,,., Filing Fine&F.
Assrnt. Other Zoning El Assmt. other Zoning
ror. -7- -26
-2 ror:
Permit # Permit #
CITY OF TIGARD CITY OF TIGAPTII
fly:
Fill 0"IN IIMQ
116 14157
A
APPLICATION - STREET IMPR' 'EMENT, "CAVATION COPY TO:
ORDIN...4CE NG, i4-14 U (WHITE)-FILE
�� (BLUE) -NSP.
(INSTRUCTIONS ON SEPARATE SHEET) U I`/ELLOW) -OTHER A,ENCY
❑ (PINK) APPLICANT
�.
APPROVED APPLICATION NO,:
NOT APPROVED ❑ CITY OF TIGARD, OREGON FEE AMT.: S
PENDING FEE. PMT. ❑ CITY HALL. RECEIPT NO.:.-.� 6
PENDING SECURITY ❑ PUBLIr'WORKSDEPARTMENT BY ry DATE '// / �b
PENDING AGENCY "OK" ❑ Application and Progress Record r i:'.
PENDING INFORMATION Cl FOR STREET IMPROVEMENT/EXCAVATION Ma►a AS REQUIRED�UIRRE l
ANNUAL L]
PENDING VARIANCE ❑ EXPIRATION DATE:
„O .�
PERMIT NO.: . .� i�G_ DATE ISSUED: _ ` I� Y I �y� , BY; pti
1 ) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL ._—L
ASS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH' TY REQUIREMENTS.
APPLICANT ,',111/11/fNt-fM OVA��" _�
CITY PHONE
CONTRACTOR 1/i/ 'fi
NAM[ ADDRESS PHONE
PLANS BY _
NAMR /. ADDR[f! T -- PHONE
ESTIMF:TED IMPROVEMENT TOTAL VALUATION ( COST: S � —_
DOLLARS
(2) EXCAVATION DATA: >
�� FOR OFFICE USE: ❑MIN.
' 0.02 X ;_ u
STRECT DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM 4 QUANTITY
�� ` :/� T�• , � 'i STREET
R 10
E _
Q
U _
ESTIMATED STREET OPENING DATE:_ / ,�Y' / G g
ESTIMATED STREET CLOSING DATE: —� [—/ / �� g
0 FSTR
(3) SECURITY NO. SECURITY AMT,: S ::L: CLOSET
SURETY CO.: ---Z Z � FINAL
CERTIFIED CHECAfH_ B _❑ OND 'I -NSI
CK C.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS
FEATURES; EXCAVATION LOCATION AND EXTENT.
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1 I I 1 )
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(5) NOTE THE: CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANT'S Tf) CONDUC=T AJORK WHERE
RIGHT Or WAY JURISDICTION 19 THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON.
THE APPLICAN i AGREES TO DEPOSIT THE REQUIRED SECURITIES, TO COMPLY WITH ALL PERTINENT" LAWS AND
CONSTRUCTION SFECIrICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THF CIIY AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
APPLICANTS SIGNATURE DATE
ry
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4PPLICA,."ON -- STREET IMPR rMENT/EXCAVATION COPY TO:
1WHITE - FI
ORDIN,_4CE NO. 74-14 (BLUE)I INS.PE
(INSTRUCTIONS ON SEPARATE SHEET) :BLUE)
OTHER AGENCY
"���� )PINK) P
.APLICANT
APPR 0VLD APPLICATION NO.:
NOT APPROVED ❑ CITY OF TIGARU, OREGON FEE AMT.: S Z':�
f'WNDIIIG FEE. PM'1`r " _ x'311 . "All, RECEIPT NO.:
QLW4a4AIG SCC.URITY A. '�.. PUBLIC WORKS DEPARTMENT BY ��
PI-NDING AGENCY ''OK'' ❑ Application and Progress Record .- — — — — — — — — — — —Q— —
MAINTENANCE DON S I- _
PENDING INFORMATION ] FOR STREET IMPROVEMENT/EXCAVATION AS 17EOUIRED
ANNUAL Ll
PENDING VARIANCE ❑ EXPIRATION DATE: /
P'z.RMIT NO.: --- DATE ISSUED: r–�_ -_1 ._-- DY:
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
e AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT ° od 1„ �ss1'1)41AGv►leC� ~�►' �� o�`�'� .3/ (1
NAM!♦¢ -- DDRESS CITY /// PHONE
CONTRACTOR._ l
'144'r^ /1J , ('^( •<�f!, l"Sps� 7 Ohl-A ,' �j �'C
NAMJ ADDRESS I ,l PHONE
PLANSBY._ _ TKof/D •� �,r ,%� ��di, /:X7.5 'S'4-1
NAME ADDRESS CITY PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ el .—
DOLLARS
FOR OFFICE USE! 1MIN.
(2) EXCAVATION DATA: 0.02 x II S = s
STREET _ DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLEDITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM & QUANTITY
STREET
OPENED
R TION
1' S i t U
ESTIMATED STREET OPENING DATE E
-- .. S
ESTIMATED STREET CLOSING DATE: T _
E
--—= _ --- --- _--._ D
3) SECURITY NO. W ` SZS51 �- SrECURITY A/M� T.: $ �' �^f_ '_ c�OSED
'URETY CO.. 1, r1-11� � `lo, FINAL
ce/a TIFIUDCHECK U CASH D BOND( INSPEC.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS j CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTENT.
1 I77
I 1 1 I
I I I
I l I I
(5) NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT-OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON.
THE APPLICANT AGREES TO nEPOSIT 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 WI-IICH MAY RESULT FROM APPLICANTS ACTIONS.
APPLICANTS SIGNATURE. __ DATE / /
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