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11150 SW 115TH AVENUE FILE NO. 4(o-1 "1 115TH AVE. - 11150 STR. OPN. PERMIT Avoid Verbal Messages A-1 CITY OF TiGARD To: From: —PION. )x Subj a<:t . _. =�� .� �� _ Date: I 1 City of Tigard I INSPECTION REQUEST for INSPECTION TIME : Z > PERMIT NO. : ' DATE: DATE ISSUED:.__.L_.L_ j OWNERS NAME . ADDRESS : �� ! 5- ,�c CONTRACTOR TEST: Ai► L], Water , Visual tel , Laboratoryc] RESULT: Approved pica pproyad-] ._ Pending (] I SKETCH: r 7 mPt=ti(,u�'� Ma#sw/ I n�� vl�� .. l I v INSPECTOR GATE CNOTEAttach suppiementai toot data heret] APPLICATION - STREET IMPRC -MENT/EXCAVATION COPY TO: OR DIN<.,.CE NC, 74-14 ❑ (WHIT[)-FILR Q ;DLUIE)•INSP. (INSTRUCTIONS ON SEPARATE SHEET) ❑ IY[LLOW)-OTHEiR AGENCY Q (PINK)-APPLICANT APPROVED Ik APPLICATION NO.: NOT APPROVED ❑ CITY OF TIGARD,OREGON FEE AM'I. s °"O_— PENDING FEE.PMT. ❑ CITY HALL � , ' RECEIPT NO.:�� , PENDING SECURITY ❑ PUBLIC INORi S DEPARTMENT BY � � DATE� /Z�'/ 2� PENDING AGENCY "OK-- ❑ Application and Progress Record _ r " - - MAINTENANCE BOND N 4( 5 #4 PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS REQUIRED ANNUAL PENDI'IG VARIANCE ❑ EXPIRATION DATE: PERMIT NO.: 41( - 17 -1' � DATE ISSUED: --1-��__ , BY: (1� APPLICATION IS HEREBY MADE TO EXCA /ATE FOR AND INSTALL §Pe,-a.- I� --- -- AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS. APPLIC�'�T -6r'.�r� 1 —�_( .4/� u�. NAME� ADDRE s CONTRA rOR_ N A• ' ,�'Irl''� l•'D" to [ Mme__' 4 �✓ � -_._ LL L�?-. T ADDRESS CITY PHONE PLANS BY _ NAM[ ADDRE43 -- �- CITY --'rHO - ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): E / - -- -==- DOLLARS (2) EXCAVATION DATA: FOR OFFICE USE nmiN`- o.o2xIII--#—e-c-, es ' STREET DESCRIPTION PROGRESS & INSPECTION STATUS NAME SURFACE CUT CUT CUT MATERIAL INSTALLED TYPE- LENG'1 H WIDTH DEPTH ITEM & QUANTITY ITEM DATE REMARKS/TYPE BY STREET OPENER I NSPE - --' E TION Q ---- U ESTIMATED STREET OPENING DATE: / / E __ S ESTIMATED STREET CLOSING DATE: T - _ L._L - -- E D 13) SECURITY NO. _ SECURITYAMT.: $._ c LO SURETY CO u.s ,A /fiend _ FINAL - CERTIFIED CH[CK l7 CASH O [OND o INSPEC. (4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPTCIAL PROVISIONS /CON DI'TIONS FEATURES; EXCAYYV`(ATIf3N LOCATION AND EXTENT. �— CURB - i �� - -1• _ _ �� A % _ =L 1 I S NOTE. THE CITY OF TIGAKO 09-IES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WOI.K WHERE RIGHT-OF-WAY JURISDICTIO,' 13 THAT OF WASHINGTON COUNTY OP THE STATE OF OREGON, THE APPLICANT AGREES TO `EPOSIT THE REQUIRED SECURITIE4, TO COMPLY WITH ALL PERTINENT LAWS AND CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY AN- EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS. )< > �. APPLICANTS SIGNATURE _ �L1L V`•' 1 �-tS.:�'1 i�'� 1 � ' �� / w DATE.-,/' / ) ! APPLICATION — STREET IMFR =MENT/EXCAVATION COPY TO: ORDINt,.gCE NO. 74-14 ❑ ( -NILE E) (BBLULUE)E) � INSP. ;INSTRUCTIONS ON SEPARATE. SHEET) [_j (FELLOW) -OTHER AGENCY ❑ IPINK) APPLICANT 'ROVED ❑ APPLICATION NO.: _ NOT ArIPROVED ❑ CITY OI' 'AGAR❑, OREGON FEE AMT.: S _ PENDING FEE. PMT. ❑ CITY HALL RECEIPT NO.: _ PENDING SECURITY ❑ PUBLICV✓ORKSDEPARTMF_NT BY ( PENDING AGENCY "UK" ❑ :application and Progress Record — — — — _. — — — — — MAINTENANCE BOND _.____-_ -___ PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION As REQUIRED ANNUAL PENDING VARIANCE ❑ EXPIRATION DATE: PERMIT NO.: - - DATE. ISSUED — -__ , BY: _--T-- (1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL - AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS. APPLICANT NAME �'----'--.� ADDRESS CITY CONTRACTOR _ NAM[ ----��- ADCRESS - CITY _ PHONE PLANS BY - ----- — —_ —----- -- — ------- --- NAME ADDRESS CITY ��_ hNON[ ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S DOLLARS UMIN. (2) EXCAVATION DATA: FOR OFFICE USE:0.02 X i =s STREET DESCRIPTION PROGRES_S_& INSPECTION STATUS NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY TYPE LENGTH WIDTH DEPTH ITEM & QUANTITY S PENE D 3-A- 77 .Ln GV r- t INSPE - --` R TION 'Q U 3-1-77 W,4 r*L rtsr ESTIMATED STREET OPENING DATE; / / E ESTIMATED STREET CLOSING DATE T�. —[ _ E --- -_ -- --- - ------.-_."_�� D (3) SECURITY NO. __ SECURITY AMT.: $ .STREET_ CLOSED SURETY CO.: _ FIN AL -� _ CERTIFIED CHECK _ CA! .. FOND n IN'S (4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICA SPECIAL PROVISIONS /CONDITIONS: FEATURES; EXCAVATION LOCATION AND r_XTENT. I I I \ 1 1 I I i 1 "I NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISd1ON TO APPLICANTS TO CONDUCT WORT, WHERE RIGHT-OF-WAY JURISDICTION IS THAT OF WASHIN^TON COUNTY OR THE STATE OF OREGON. THE '.PPLICANT AGREES TO DEPOSIT THE REQU�RED SECURITIES, TO COMPLY WITH ALL PERTINENT LAWS AND CONSTR.JCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK. AND TO SAVE HARMLESS THE CII Y AND EMPLOY :ES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS ANTS SIGNATURE DATE v - l�_ CITY OF TIGARD Date 7 .,P �77 Amount _�..��.-.c_• _r��_._a- G`-'/'"''--�_., dollar: Name Cash J M.O. , Address Bldg. St.opng. Bus.Lic. ❑ P!bg. Pubc!ns. - Bike Lic. Elctl. Copies Sew.Serv. Sewer Filing - Fine&F. • L� Assmt. other - E] Zoning F --- - -- -Ems.'_.`-._-�`_ •=�I�f.� _ Permit # CITY OF TIGARD MMITCM(N►NIV1•N6�111• f•M1� 16099 UNITED PAC1FSC/RELIANCE i \• INSURANCE COMP/ i CERTIFICATE OF INSURANCE PROtECTUN Tp�GMA.aiASniHG�)N !,t (:'lJecr un Date of'This Certificate This is to certify that the policy(ies) described below has peen issued by th-e Company designated as insurer, only to the Insured named below. Any requirements or any provisions in contracts or agreements between the Insured and any other person, firm or corporation shall not enlarge, alter or emend the definition of Insured or any of the terms, conditions, exclusions, or limitations of the policy(ies) described below. That prGc."(ies), subject to all of its limitations of liability, 1 coverages, hazards, exclusions, provisions, conditions and other terms,:s in full force and effect as of the date this certificate was issued. Name of Insured H. Odell F'earson.09A Pearson Construction Company Addressof Insured 7`-)2-5 S•W•Varns,, Tigard, Oregon 97223 COMPREHENSIVE L IABILITY - Insurer:YLJx United P_,cifir, Insurarn.e Company ❑ Reliance Insurance Company Policy Number LP 3 0'172 16 Effective 4/26/74 Expires 4/26/77 COVERAGES LIMITS OF LIABILITY MULTIPLE LIMIT PLAN:Automobile Each Person $ Each Occurrence I Bodily Injury $ Liability Other than Automobile $ $ Each Urrurrence $ Aggregate Products Hazard and r Completed Operations Herard 4t Property Damage—y AutomoLile $ Each Occurrence Liability Other than Automobile $ Each Occurrenr•e S Aggregate r SINGI E LIMITPLAN: Property Demago 6Wk"'X excludes blasting or explosion. Noddy Injury Liability Automobile s 300,000. Foch Occurrence and Propertythan Au tnmobile $ 300 000. Each Occurrence $ 300,000. Aggregate Property Damage Liability t EXCESS—UMBRELLA— Insurer: ❑ United Pacific Insurance Company ❑ Reliance lnsuranca Company Policy Number Effective Expires Limits of Liability a. $ Limit in all in respect of Each Occurrence b. $ Limit in the Aggregate for Each Annual Period where applicable Location of Risk and Description of Operations In accordance with the above, the captioned policy(ies) insures the liability of the Insured named above arising from (1) operations by or on behalf of the Insured,or (2) premises or property used by or on behalf of the Insured in connection with such operations;subject, however,to all the provisions,exclusions and limitations of the policy(ie•..). The Nhcy(ies) provides, under the Insuring Agreements, contractual liability coverage with respect to any contract or ` agreement wholly in writing.Stich contractual covarage Is subject to all the exclusions,conditions and other provisions of the I above policy(ies). t Cancellation Provision I It is agreed that this policy(ies) cannot be cancaed without first givmy days written notice to r ' Notice This certificate is issued as a matter of information only and, as such, neither affords any insurance nor confers any rights upon the holder. It neither affirmatively nor negatively amends, extends or alters the coverage afforded by the policy(ies) identified above. Except as specifically provided for in this certificate,United Pacific Insurance Company or Reliance Insurance Company has no duty to notify the party to whom this certificate is addressed as to any changes or t.dncellation of the policy(ies) and shall not be rgsponjible for any failure to do so. Date 77 To City of Tigard 11 Address T igard, Oregon Countersigned by -<Yo rzEPi .�TATIVe Boyd & Co. Insuronce ,aceraat L•3351 10/78 0-694 ��5 vx UNITE"' PACIFIC/RELIANCE �n j` �'j-D' cc. v� INSURANCE t._ APANIES S CERTIFICAT'-. ` Pr14Y 2 13 7� OFINSURANCE 7ROTlC1,ON ,ACOM^ WA.MINaron In Effect on Date of This Certificate This is to certify that the pcoo(14,Q k,. d below has been ircued by the Company designated as insurer, only to the Insured named below. Any requirements or ny provisions in contracts or agreements between the Insured and any other person, firm or corporation shall riot enlarne, alter or amend :he .Iefinition of Insured or any of the terms, conditions, exclusions, or limitations of the policy(ies) described below. That policy(ies), subject to all of its limitations of liability, coverages, hazards, exclusions, provisions, conditions and other terms,is in full force and effect as of the date thi i certificate was issued. : Name of Insured CD " !�ZA.1.3i '- ' ^lI2'• h. :,.ui 0 i':�tt�SCi�i CC,.aTI�Ut. �,,i Ct Address of Insured 752GJ' 1f, y„ t;;v t .1 T^ •Dt 0-.LG0,T ;7223 .i COMPREHENSIVE LIABILITY— Insurer: United Pacific Insurance Company ❑ Reliance Insurance Company Policy Number LP 64832?1 Effective 4-26-77 Expires '-26-79 COVFRAGFg LIMITS OF LIABILITY MULTIPLE LIMIT PLAN: — 8nally Injury Auturnnhtle $ Each Person $ Each Occurrence Liabil,rr Other theft Automobilo $ $ Each Occurrence -Y $ Aggregate Products Hazard and ampleted Operations Hazard Property Damage Automobile $ Each Occurrence Liability Other than Automobile $ Each Occurrence $ Aggregate • SINGLE LIMIT PLAN: Pig f --2 Y C�• �^ =, �T+�-*` T "t M 'PWSiG:T. •. —.a '4.11 i:i Jd(►„LU Li.d �..EW1l.�lur C�� laa��� Bodily Injury Liability Automobile ! 3001,000. Each Occurrence -end Property Damage Liability Other than Automobile S 30o t 000. Each Occurrence $ "0,0r,)0. Aggregate EXCESS—UMBRELLA— Insurer: ❑ United Pacific Insurance Company ❑ Reliance Insurance Company Policy Number Effective Expires Limits of Liaoility a• $ Limit in all in respect of Each Occurrence b• S Limit in the Aggregate for Eanh Annual Period where applicable Location of Risk and Description of Operations In accordance with the above, 'he captioned policy(ies) insures the liability of the Insured named above arising from (') operations by or on behalf of the Insured,of (2) premises or propert, sed by or on behalf of the Insured in connection w-,h such operations;subject, ho,vever, to all the,provisio, s,exclusions and limitations of the policy(ies). The policy(ies) provides, under the Insuring Agreements, contractual liability coverage with respect to any contract or . agreement wholly in writing. Such contractual coverage is subject to all the exclusions,conditions and other provisions of tlfr. above policy(jes). :.y Cancellation Provision It is agreed that this j olicy(ies) cannot be canceled without first giving (10) TZX days•.vrjtten notice to Notice This certiricate is issued as a matter of information only and, as such, neither affords any insurance nor confers any r upon the holder. It neither affirmatively nor negatively amends, extends or alters the coverage afforded by the policy(iss) ti identified above. Except as specifically provided for In this certificate, United Pacific Insurance Company or Reliance Insurance Company hras.: no duty to notify the party to whom this certificate is addressed as to any rhanges or cancellation of the policy(ies) and shall not be responsible for any failure to do so, +tl, Date To Address T-”�:t,.��- Countersigned by .. ���:a ��T UTNURI2E�REPRESEN ATT IVB � ;,y N L 3351 16/75 p•