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14255 SW 112TH AVENUE FILE NO. � 112TH AVE. - 14255 STR. OPN. PERF APPLICATION - STREET IMPR( f-MEN T/EXCAVATION �j PWM(WHITE) FILE ORCIN,. .CE NO. 74-14 ❑ (BLUE) INSP. ❑ (YELLOW) -OTHER AGENCY (INSTRUCTIONS ON SEPARATE SHEET) ❑ (PINK) APPLICANT r APPROVED El APPLICATION NO. 17-2- NOT APPROVED ❑ CITY UI• fIGARD, 01117GON FEE AMT.: S. 0 Q _ PENDING FEE. PMT. -� - CITY IIALL RECEIPT NO.: �J a��w�a�sEcurrrr� --- PUBLIC WORKS DEPARTMENT BYr�!' '_ - DATE_ PENDING AGENCY "OK" ❑ Application and PToRTess Record MAINTENANCE BUND PENDING INFORMATION 0 FOR STREET IMPROVEMENT/EXCAVATION AS REQUIRED ❑ ANNUAL 1 PENDING VARIANCE ❑ EXPIRATION DATE..: ` � eERM1T NO.: _...._ - DATE ISSUED: -- - - - --- - BY: 1 ) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL ._SgS�L••!r AS DESCRIBED HEREIN, IN FULL ACCORDANCE WIIT ITY REQUIREMENTS. APPLICANT _ --- (� -' _l� ia� l. � ,.1�.14 `',�'' ` ADDRESS CITE PHONE CONTRACTOR-fes-J-� -.- N M 1r`� ADDRESS CITY \ PHONE PLANS BY=���yM - NAME�-A Lf-I5---=ADURES$ CITV PHONE ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ — DOLLARS --� -- --- Fon OFFICE USE' iIMIN.- - (2) EXCAVATION DATA: STREET _DESCRIPTION PROGRESS & INSPECTION STATUS NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM ^ATE REMARKS/TYPE BY TYPE LENGTH WIDTH DEPTH ITEM & QUANTITY STREET F N D _. INS 1 R TION U - ESTIMATED STREET OPENING DATE: LC, / -s. ET ESTIMATED STrIET CLOSING DATE: ___ 1 �- / 1 / 7 S - ED - — -� STREET (3) SECURITY NO. --_ SECURITY AMT.: $ _ CLOSE _ SURETY CO.: FINAL CERTIFIED CHECK '.I CASH ❑ •ONO U INSPEC. ., . (4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS FEATURES; EXCAVATION LOCATION AND EXTENT. I n,.. .f 1 1 pig 1 1 ••1, ,1�?� 1 I _�._�-- Y (5) NOTE THE CITY OF 'TIGARD DOES NOT. HEREBY, GRANT PERMISSION TO APPLICANTS 'TO CONDUCT WORK WHERE RIGHT-OF-WAV JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON, THE APPLICANT AGREES TO DEPOSIT THE RCQUIRED 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 WHILH MAY RESULT FROM APPLICANTS ACTIONS. � ^^ 1 APPLICANTS SIriNATURE ""'�� DATE � LJ 1 1 APPLICATION STREET IMPP 'EMENT/EXCAVATION COPY TO: ORDIN. ..aCE NO, 74-14 Ej ((BL BITE) E -INSPNSP, Ej (YELLOW) -OTHER AGENCY (INSTRUCTIONS ON SEPARATE SHEET) (PINK) - APPLICANT 'ROVED (_1 APPLICATION NO.: _17 _T APPROVED ;l CITY OF T'IGARD, OREGON FEE AMT.: f—PENDING FEE. PMT. (_] CITY HALL REA-E1PT NO.: PENDING SECURITY ❑ PUBL;CWORKS DEPAI;i-MEN7 BYDATE I ��— PENDING AGENCY ''OK" Ll Application and Progress Record MAINTENANCE BOND at PENDING INFORMATION U FOR STREET IMPROVEMENT,'crXCAVATION AS REOUIRLD ANNUAL PENDING VARIANCE L 1 EXPIRATION DATE: PERMIT NO - - ---- - DATE ISSUED: — L -1_ -- BY: - - ------ - ---- (1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND IoISTALL -_- _ - AS DESCRIBED HEREIN, 1N FULL. ACCORDANCE WITH CITY REQUIREMENTS. APPLICANT NAME - ADDRESS C'TV PHONE CONTRACTOR _ -------------------DRESS- NAME ADDRESS C11'V PHONE PLANS BY - ---- NAME —_� ADDRESS CITY PHONE— ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): DOLLARS (2) EXCAVATION DATA: 0.0 oFFlcc usE: MIN _ o.oz x s _ - s STKFET DESCRIPTIONPROGRESS & INSPECTION STATUS NAME SURFACE CUT CUT CUT MATEPIAL INSTALLED ITEM DATE RF-MARKS/TYPF. BY TYPE LENGTH WIDTH DEPTH ITEM $ QUANTITY --' --- -- STREET _ — QPENL•D 4 INSPEC- E TION Q F_STIMATE D STREET OPENING :j ITE:__� __L— � FS ESTIMATED STRISET CLOSING DATE: F STREET (3) SECURITY NO. _ SECURITY AMT.: Z CLG9F. SURETY CO.: �. FINAL CRTIFIED_ CHECK Il CAiM U BOND i INSPEC, ) E (4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS /CONDITIONS: FEATURES; EXCAVATION LOCATION AND EXTENT. 1 ( 1 I —>r -CUA% --- I I I I I (S) NOTE: THE CITY OF TIGARD DOES NOT, AERERY, GRANT PERMISSION :'O APPLICANTS TO CONDUCT WORK WHERE RIGHT-OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR T14! 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 AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS. APPLICANTS SIGNATURE DATE _ I �Y OF TIG/\RD -7 ,� Amount dollars �_�____— <J-- --� Oates /C - �v/� — - � Cash U M Name Address �1 =� 7 __- 2(,tc ❑ Bus.Lit. ❑ ❑ r St.�P^g• C3. Bldg. - ❑ Bike Lit. ❑❑ Putt^sServ. Plbg. Saw. ❑ ❑ copies - (Ictl. fine&filing F- sewer ❑ Sewer Zoning ❑ ether - Assmt. for: Pertnil # TIGARD CITY �F 13041 !