13465 SW 107TH AVENUE FILE NO. -CID
107TH AVENUE - STR. OPN. PERMIT
a CITY OF 'ZIGARD
EXPENDMU?r RBQUL,`,T
Mi.s form is a multi-use form. Appropriate receipts imist be attached. Documentation
is important for all Vwposes. Staple documentation to form.
VENDOR NO.: —_ DKr'E:
f' PAYABLE Tp: �5 L RDQUESIED BY:
_1—!'1 -
Approved request due Wednesday
10:00 AM to A/P for:!
by
Friday.
< MISCQ�ANDOUS EXPENDIT=:
Date Description, Invoice No., etc. :,000unt No. Amount
Cro
REFUi .. ►J -- 1 C -ZZOOCU _
IL4�kkttil_I*
Mileage $0 255 =-- --- - _-
APPROPRIATION BAIANCr: AS OF: :,rGNAIM,:
(Up to $25.00) Sechtion Mmiager — Mirc-h. Agent
($25.01-2,500.00) Division Winager
($2,500.01.-7,500.00) Dept, Head
($7,500.01-15,000.00) City Administrator
($15,000.01- ?) Local Contract Review Floard _
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23
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IMPOiSTANT MESSAGE)
FOR—
DATE
OR
;j A.M.
L7ATE TI d P.M.
O F l� —�---
PHOWE
AREA CODE NUMBER f
TELEPHONED PLEA Q, '
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH —
P�ETURNED YOUR C l SPEMAL A TTENTION
MES
SIGNELI �`-
LITNO IN U.B.A. V, 07
7CP3 9 FORM 30OPP
INSPEC- '()N NOTICE
City of Tigard ouilding Department
P.O. Box 23397
Tigard. Oregon 97223
Phone. F-19-4175 /
Type of Inspection
Date Requested 134k5c' Time A.M._ • P.M.
Address Y � �' — Permit *—,5&-;2
Owner '
-- _ Lot #
Builder
The following Building Code deficiencies are required to be corrected:
-e ,p J 5 7�y�'�" - -- 1 t?Z_SC� "2d v i S e vnn P_
Wo 0-4OF
G o
Present0 to
Inspector ' - ❑ Olplppm"d
Dot. – - —
CALL FOR REINSSPF,C�TIO�
L-01YES =O
APPLICATION — STREET IMPRO' 1ENT/EXCAVATIONc PY TO:
ORDINANCE NO. 74-14 �( -FILE
;(YYELLOELLO W)-INSP.
(INSTRUCTIONS ON SEPARATE SHEET( ❑ (PINK)-OTHER AGENCY
(BLUE)-APPLICANT
APPF OVED APPLICATION NO..
NOT APPROVEDCITY OE'' F
TIGARD, OREGON C: r_
❑ EAMT.: ; 4^ p�
PENDING FEE. PMT. 11 =_-
CITY HALL RECEIPT N �___�LO1 Soo
PENDING SECURITY ❑ PUBL/C WORKS DEPARTMENT BY_-� DATE—SC= /CS /�—
PENDING AGENCY "OK'' ❑ Applu.Ition and Progress Record
PENDING INFORMATION ❑ MAINTENANCE BOf�D iF_
FOR STREET IMPROVEMENT/EXCAVATION As Rrclui, eu �J ��
ANNI'AL ❑
PENDING VARIANCE ❑ EXPIRATIO DATE: IIAC�•L
PERMIT NO 36%� lel DATE ISSUED �.._I. '. L -T� BY
(1) APP C TIO IS HEREBY MADE TO EXCAVATE FOR AND INSTALL`.'_:
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT _ t� e.l - �,54'O sLQ� —._..__ O. �{�,.� DV. E►4fo-ZOS
IA E ADDRESS ��CITY`'�T PHONE
CONTRACTOR_ 2vv1
ADDfiE6 CITY -T�MONE y
PLANS BY
NAME l.DDRESS CITYN1 O'NE—
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $
DOLLARS
(2) EXCAVATION DATA: W -FomOFFICEYY��`E:''r ' - n MIN.
_ 0.04 X ;
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CL.'T MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
_ TYPE LENGTH WIDTH DEPTH ITEM a QUANTITY____ _
STREET
PFN D
S —
t � -v,J1 R TION
E - —
O
ESTIM4l EED STREET OPENING DATE: _ L � � S
ESTIMATE")STREET CLOSING DATE. / T ^�
D
5 T R F E T
(3! SECURITY NO. SECURITY AMT: S . [DO — CLOSED
SURETY CO.: _ _ FINAL A M
CE RTI FIFO CHEA ►CK N FOND C INSPEc. 7 2 TL tV c N
(4) PI.O'f PLAN. INDICATE SITE PERTINENT PHYSICAL SPECIAL P O BIONS /CONDITIO
FEATURES. EXCAVATION LOC EXTENT.EXTENT. � �vx,.
c II IS�VS 1 t# - 1-7
1 I
CURB
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(5) NOTE THL" CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHTOFWAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON,
THE APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURITIES, TO COMPLY WITH AL1, PERTINENT I.AWS 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
APPLICANTS SIGNATURE .G ~� L� t.� DATE ����/(( o
o �
CO
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CITY
NAME op RECEIPT OF F"AYMENT RECEIPT NO. 02
ADDREES : COOPER MANUFn--TURING CHE0-'-'-' AMOUNT 8
: 6S40 SW F4LFREL CASH AMOUNT 104. 00
PAYMENT DATE- - 0. DO
PORTLAND, OR 97223-- SUBDIVISION
PURPOSE OF PAYMENT AMOUNT PAID P.URPOSE OF
CUSTOMEF;—CE-P-E-- FA�'MENT AMOUNT PAID
100. 00
4. 00
STREET OPENING PERMIT .367-90
TOTAL AMOUNT PAID
104. 00
COOPER MANUFACTURING 8433
6540 SW ALFRED 246-2051
A POHTLAND, OREGON 97223
PAY TO THE
ORDER OF
r"DOLLARS
U.S.
51
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OM BRANCH
P.O.
W()X 488 8FAVFRt0N.on 07078
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