11550 SW 98TH AVENUE-2 FILE NO. �
98TH AVENUE — 11550 STR. OPN. PEbMIT
I
1'
APPLICATION — STREET IMPRC MENT/EXCAVATION COPY TO:
ORDINAINI"E NO. 74-14 1>� (WHITE)-FILE
(YELLOW)-INSP.
(INSTRUCTIONS ON SEPARATE SHEET) Sk(PINK)-OTHER AGENCYBL-dG
K (BLUE)-APPLICANT
APPROVED ;1k, APPLICATION NO.:
NOT APPROVED CI I Y OF TIGARD, OREGON FEE AMT.. f
PENDING FEE. PMTCITY HALL RECEIPT NO,: `?0 _-. 0_30y�
PENDING SECURITY [] PUBLIC WORKS DEPARTMENT Br ,, rte._ DATE � 1.2`�I �I0
PENDING AGENCY ''OK'' [] Application and PrOgrCss Record _ - _ `-
MAINTENANCE BOND i►
PENDING INFORMATION p FOR STREET IMPROVEMENT/EXCAVATION AS REQUIRED ---
NNUAL
PENDING VARIANCE 7 EXP.0ATION DATE
PERMIT NO �_J �G�_ DATE ISSUED: - ---- Ly1��� , BY:
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTAL[- '-'% 717,7-At � t'
r d tS1�r�eg( Q`';Q6 it, AS CIL.SCRIBLD HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT Farm } , /Z�l� v¢.r fQ /�7u3
11Y�1[ AME AODRE!! 0 eCITY —pjlpN
CONTRACTOR I _ _ )' I 1
NAM
CITY
E _ ►HONE
PLANS BY
CITY PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ ; 1�c) 00
DOLLAR!
(2) EXCAVATION DATA: FOR o5"F_'ui_F- -` ___- _-- FM�N�'
0.04 X f L'C� f —LLL. r0
STREE _ DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED
TYPE LENGTH WIDTH DEPTH ITEM A QUANTITY ITEM DATE REMARKS/TYPE" BY
JLLi STREET --
P N D
INSP C- _
R TION
E
Q
ESTIMATED STREET OPENING DATE _ / j E.
S
ESTIMATED STREET CLOSING DATE / / T
E
(3) SECURITY NO, _ _,_ SECLKITYAMT.: t / 9-5"0. 0C', STREET
SURETY CO., FINAL
C[RTI FIEo cf�Er-h CAIN YY SONO r SPECIAL PROVISIONS t
EC
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SIONS/CONDITIONS:
FEATURES, t KCAVATIUN LOCATION ANU EXTENT. I
#d-evlrsirseo) i li1l� �.'crk shall c*r,��rr,-t t�
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(5) NOTE THE CITY OF TIGAPO DOES JOT, 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 DEPOSIT THE REQUIRED SECURITIES, TO COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK, ANO TO SAVE HARMLESS TAE CITY AND
EMPLOYEES AGAINST A14Y INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS
APPLICANTS SIGNATURE ' �L !
CrrY OF '171GARD
DMENDIIURF RD�UEW
Mils Form is a mlti-x;se form. Appropriate receipts mist be attached. Documentation
is igxxLant for all purposes. Staple docum_ntation to form.
VEHXR NO.: _ Y DATE: A7 _ 3D —70
PA3MBIE 'IU: � `�uwy�i�•c��n��- FL''XZiJFv!'ID BY: —
123
AMr0Ved request e Wednesday
10.00 AM to A/P for checks by
Friday.
MISCEIIANEOM EXPFNDIZ[1F2F5: —
Date Description, Invoice No., etc. Account No. Amount
Z'Z000 $ I 1�h do
r\
Mileage $0.255
APPROPRIATION BALANCE: - _-- AS OF: - -- SIGNATURE: r
(Up to $25.00) .'tion Manager 9 _ __.--_ F irc-h. Agent _—
($25.01-2,500..00) Division nam.rger
($2,500.01-7,500.00) Dept. Head
I ($7,500.01-15,000.00) City Administrator
($15,000.01- ?) Local contract pEview Board i ---
ke/1501-F
I T`'
:F 7' RECELIPT OP PAYNENT REC�EIPT NO. :9(',—Z(."3(.)47
CHEC-K.' AMOUNT 2028.00
NAI E 1-:*ENNEr,V P"LUMING
ADDRESS :139GE FAF�MTNC��CN RE, C LASH AMOUNT 0."X)
PAY11ENT DATE 07J 4/9
SEAVFRTC.,�,j OF"
SUBDIVISION
PURPOSE OF FAYI-{'N, AMOUNT PAID PURPOSE OF PAYMENT AMOUNT PAID
"USTOMER
='ERPIIT NC. 7-77--o-,
'011"AL ArIOUNT Pr4lr) '1028. 00
KENNEDY PLUMBING, INC. 20954
139135 SW. FARM114GTON RO. 643-5535
BEAVERTON, OR 91005 24-12 15
go 1236-'
PAY
TOTAL TO THE
ORDER OF
DOLLARS
tIntonirtate Bank
First of OreW,N.A.
Interstate Raleigh Hllla.�irmnch
P.O.Dox 25155
Bdnk Portland,OR 91225
1100 20954110 e30001231: 1 15 00207 8ll-