12820 SW 107TH COURT KLE NO. 'j�(,
107TH CT. - 12820 S R. OPN. PERMIT
CITY OF TIGARD REQUISITION
TIGARD, OREGON THIS IS NOT A PURCHASE ORDER NO 16847
PLEASE ORDER THE FOLLOWING: P.O. NO.--
SUGGESTED
O.SUGGEST D SUPPLIER:
NA_MEDATE ----- -- /�77
STREET _.-_ DELIVERY TO_ DEPT
ADDRESS _
CITY d ZIP CODE — -- ----- - -- —_—__
DATE NEEDED
ACCOUNT NO. QUANTITY
DESCRIPTION — -�� U, ITPRICE AMOUNT—T
PRICE- -_f.—.-----
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SPECIAL INStRUCTIONS
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SIGNATURE
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APPidVED —
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APPROVED
APPLICATION — STREET IMPRf—MENT/EXCAVATION COPY TO:
OPDIN#,..CE NO. 74-i4 'T3'(WHITE) - FILE
'G'IBLUEI -INSP.
(INSTRUCTIONS ON SEPARATE SHEET) 'ffV❑ IVELLOWI -OTHER A.ENC'+
IPINKI APPLICANT
APPROVED `6d APPLICATION NO.:
PJOT APPROVED /❑" CITY OF TIGARD,OREGON FEE AMT.. S -- --_
PONDING FEE. PMT. �� CITY HALL. RECEIPT NO.: l��-��-� ------
PENDING SECURITY c`' PURL/C WORKS DEPARTMENT BY _� 1= "ak-E .1 2
PENDING AGENCY "OK" Q Application and Progress Record
MAINTENANCE BOND of
PENDING INFORMATION O FOR STREET IMPROVEMENT/EXCAVATION AS RFOUIRED ><
—
ANNUAL
I PENDING VARIANCE EXPIRATION DATE: I Z-1l7l 77 _
PERMIT NO.: r' /I% DATE ISSUED: _-L?_L.__ L�__ . BY:
SIR
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL _.—_ .
LI_�. ___=��I •;?t � ________ -
11L.2e.a- V,I IF AS DESCRIBED HEREIN, IN FULL ACCORDANCE
�wWITH CITY REQUIREMENTS.
APPLICANT 5v1' r' L/16 1. SII ,Dlte_ 7C ?_ _ ZS- 71
NAME ADD/ CITY PHONE
CONTRACTOR AtlDR[ ITY PHON[
PLANS BY
1
N ME AD [f9 //� CITY PHONE -
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S _ 4 5S.�
0. __—
__ DOLLARS
FOR OFFICE U 6: MIN.
(?; EXCAVATION DATA: _ o.oz x s = $ 91
STRELT _ _ DESCRIPTION _ PP_OGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM 6 QUANTITY _
CSTREET, N
INS
R TION
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O
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ESTIMATED STREET OPENING DATE: /Z -77L- Ey
T
ESTIMATED STREET CLOSING DATE: ZZ_ / 7 / 7 E
-_� _. _ -� ----- D -
�- e�p� STREET
(3) SECV TY NO. 559 S CURITYAMT.: S sem•_ CLOSE
9tlRfi'1"Cd : re o� r I/ 6,W11 I go, FINAL
CERTIFINSPEC. 04
(4)
L4 11
[D CM, CAfN SONf] I]
(4) PLOT PLAN: INDICAT 8EJITE-_PERTINENT PHYSICAL s SPECIAL PROVISIONS /CONDITIONS:
FEATURES: EXCAV TION LOC TION AND EXTENT.
l 1 (s' 0,�. 1 � 1 J
1 7 Q 1 f
1 1 `� 1 1
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(5) NOTE THE CITY OF TIGARD ODES NOT. HERESY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT OF-WAY JURISDICTION 19 THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON.
THE APPLICANT AGIVEES TO DEPOSIT THE REQUIRED SECURITIRT, TO COMPLY WITH ALL PERTINENT LAWS ANh
CONSTRUCTION SPECT"ICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY ANr,
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
I
APPLICANTS SIGNATURE DATE Z L 7 __
APPLICAI ION - STREET IMPR'" -MENT/EXCAVATION COPY TO:
(WHITE)-FILE
ORDINr„sCE NO. 74-14 �I
I� IBLUEI -INSP.
(YELLOW) -OTHER AGENCY
(INSTRUCTIONS ON SEPARATE SHEET) [) (PINK( APPLICANT
'ROVED {] APPLICATION NO,:
NOT APPROVED E] CITY OF TIGARD, OREGON FEE AMT.: E
PENDING FEE. PMT. CITY HALL RECEIPT NO.:
PENDING SECURITY Q PUBL IC WORKS DEPA R TMEN T BY __ DATE-�_��_
_ _ — — r — _ — _ _ _
PENDING AGENCY "OK" L] Application and Progress Record
MAINTENANCE BOND �
PENDING INFORMATION ❑ FOR STREET I MPROVEMFNTI'EXCAVAT ION AS REQUIRED ❑
ANNUAL ❑
PENDING VARIANCE i 1 EXPIRATION DATE: L
PERMIT NO. DATE ISSUED: / FAY: _
j 1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
AS DESCRIBED HEREIN. IN DULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT
NAME_ _ADDRESS - _- -- - CITY PNONE_ __—
CONTRACTOR
NAME---'�--- - --_ADDRESS_---- --- CITU ----- PHONE
PLANS BY
NAME ADORERS � CITY � TOMO-NE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): E
DOLLARS
(2) EXCAVATION DATA:
FOR OFFICIE use - -- ❑MIN.
0.02 X f
STREET _ DESCRIPTION PROGRESS & INSPECTION_STATUS _-
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM & QUANTITY
STREET
PEN D__ et _
IN SIP
R
E
QU .S/ _flSc
ESTIMATED STREET OPENING: DATE: � E
—---- s
ESTIMATED STREET CLOSING DATE: 1
(3) SECURITY NO. .. SECURITY AMT.: E _.. CLOSET
SURETY CO.. _ FINAL
-__ CERTIFIED CHF CK ❑ __-_-CASH ❑ SON u_'_
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL r r SPFCIAI PROVISIOMS /CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTENT.
1 I 1 1
1 1 I I
NOSE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS 1'0 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, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINSI ANY INJURY OR DAMAGE WHICH MAY RESUI T FROM APPLICANTS ACTIONS,
APPLICANTS S!GNATURE _ DAT!
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