14180 SW 103RD AVENUE FIDE NO.,�*_-Ap-q(
103rd AVENUE - 14180 STR. OPN. PERMIT
I
(-TrY OF TIGARD
Mmamr= 12 x1Esr
'111-i-S, form is a )TUIti-use form. Appropriate receipts must be attached. Docxmimtation
I..; important for all purposes. Staple documentation to form.
VENDOR No. : ------ C7
LMT
PAYA=- IM: Melvin R vl� Ak fro Ps;A— REQM-MIM BY.
----LIAF'o S.W. 4g
9 -7 z Z4- 1
Approved reque§t due Wednesday
10.00 AM to A/P fo-- checks by
Frida,,.
Date Description, Ii-rvoi-y-, No., et-. Arxxxmt. No. Amount
- -T
!t4 W 911-ZIS675
TOPAL $
Mileage $0.255
APPROPRIATION P-UMCr. AS OF: .31MAIUM
(Up to $25.00) Section Manager Parch.
($25.01-2,500.00) Division K-Uvige-L.
($2,500.01-7,500-00) Dept. Ifead
($7,500-01-15,000.00) cit,
.1 Administrator
($15,000.ol- '?) Local Contract Review Bcaix]
I
APPLICATION - STREET IMPRO""MENT/EXCAVATION COPY TO:
ORDIN/. ..E NO. 74-14 R) (WHITE)-FELE
91 (YELLOW)-,NSP,
(INSTRUCTIONS ON SEPARATE SHEET) ® (PINK)-OTHER AGENCY
VV I[) (BLUE)-APPLICANT
AFPROVED 2 APPLICATION NO.
NOT APPROVED ❑ CITY OF TIGARD, OREGON FEC AMT.. S _ 12.00
PENDING FEE. PMT. ❑ CITY HALI, RECEIPT NO. 91-215825
PENDING SECURITY p PUBL IC WORKS DEPA R TMEN T BY J.S..H. DATE 7 /29 /91
PENDING AGENCY "OK - p .Application and Progress Record
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION MAINTENANCE SONO #e
,15 REQUIRED BI
ANNUAL
PENDING VARIANCE 11FXPIRATION DATE:
PFRMIT NO,: BY"�i DATE ISSUED: ___�---� .(_[ g_I
4,
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL- _SALULARY-SE74ER_,gERV ,=____
STEL--j TA AS DESCRIBED HEREIN. IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT MELVIN_& ELAINE PROPST 14180 S.W. 103RD AVE. _ TIGAt OR 972.2. 3 # 639-2403
NAME —'�-- ADOR[SB RACITY - PHONE CONTRACTOR MILLER & SONS CONTRACTORS RT. 5 BOX 62 SHERWOOD ORt 625-6562
NAME ADDR[78 _. — CITY -- - ".. ......
Nit
PLANS BY_ PER_CITY STANDARDS & SPECIFICATIONS
NAME -ADDR EBS ---
ESTIMATED IMPROVEMEN T TOTAL VALUATION ( COST): 5 300.00
DOLLA
(2) EXCAVATION DATA: FOR
R OFFICE U8E`�------ MI
� ----1- _
- 114.
0.04
-_-.
0.04 X $—300-00 = S
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED
TYPE LENGTH WIDTH DEPTH ITEM AI QUANTITY ITEM DATE REMARKS/TYPE BY
STREL'T
PNN
S.W. 163RD AVE. (SEE ATTA HED) INY o,
u
ESTIMATED STREET OPENING DATE:_ / .3 l / I E
ESTIMATED STREET CLOSING DATE: / /
_ - E
D
(3) SECURITY NO. . SECURITY L+MT S 300.00 STREET
- CLOSED
SURETY CO FINAL c+
�_ _—_._*zxXfXWKCHULK X CASH soNr INSPEC. I �11 IewCt C,v_
I (4) PLOT PLAN: INDICATE SITE rIERTINENT PHYSICAL s sY SPECIAL PROVISIONS /CONDITION,
` FEATURES; EXCAVATION LOCATION AND EXTENT. 1. Notify Carl Vieweg, Ci�y
1 I o 3 ) I Inspector (#639-4171) 24 hrs.
work v(no I 1 , _ before starting work._
1 1.I
area �' �' 1 , 2. All work shall conform to City
-+IKiv- � � ( - X _
CURB 'I y `� _ _ _ _ _ _ _ _ _ ,� _ _ _ r Standards & Specifications.
1 U 3. ORS 757.541-.571 applies
W.-103rd AVE _ - -
1 - (re: prelocation of utilities,
4. Traffic control shall be
- I i +-�- — , 1• _ provided for by the contractor
1 I 1 ) 5. A_hard-surface patch is
_rNuired at the end of each da s
work.
(S)^ NOTE THE CITY OF TIGARD DOES NOT, ftEREBY, GRANT PERMISSION TO APPLICANTS 'TO CONDUCT WORK WHERE
RIGHT-OF-WAY JURISDICTION IS T11'T JF 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, AND TO SAVE HARMLESS THE CITY AND
EIIPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS,
L
APPLICAN-S SIGNATURE — I� ` /NT�i�`t DATE
r..
CITY Or 'P I C;G1Rll RECF 1 F'T or F,AYMENT RECE I 91- 8
2.5
CHEK AMAAMOUNT : 31 5
NAME ; r ROPOs-r. MF;L'. F I! N.
CCi5H AMOUNT kt, 00
3
ADDRESS 14180 5W 103RD C'f1YMCNT DATE 07lc':i'.9
SUBDIVISION
TIC?ARD, OR 972 :4••
pUkPOGE. OF PAYMENT AMOUNT PAID PURPCISE OF PAYMENT AMOUNT RAIU
CUSTOMER DEF'O .00.00 PUBLIC IMPROV
STREET OPENING PERMIT
TOTAL. AMOUNT PAID - - -> 31 H:. 00
1 i4 i
Mi viN R.PROPST 1848
i OR ELAINE A. PROPST
14180 1 03 �� 19 ?,� 1,
TIaARn,OR OR 972247224
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1500 2100 11503 1301
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