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11040 SW 119TH AVENUE FILE NO. 119TH AVE. - 11040 STR. OPN. :?ERMIT APPLICATION — STREET IMPRO' (WHITE`RENT/EXCAVATION co I..I (WH -FILE ORDINAI....E NO. 74-14 (BLUE) -INSP. (YELLOW)-OTHER AGENCY (INSTRUCTIONS ON SEPARATE SHEET) (Plt4%)- APPLICA74T APPROVED APPLICATION NV.: _s P NOT APPROVED ❑ CITY OF TIGARD, OREGON FEF_ AMT.: S4:91�_ PENDING FEE.PMT. E) CITY HALL RE IAT NO.. -1A-17 1 PENDING SECURITY ❑ PUBLIC 49RKS DEPARTMENT DY � LATE---!__1_ZL_/_fe PENDING AGENCY "OK" ❑ Application and Progress Record MAINTENANCE BOND A 3 V PENDING INFORMATION 0 FOR STREET I MPROVEMENTIE XCAVAT ION A5 14^;4UIR[D KIK.., ANNUAL. PENDING VARIANCE ❑ EXPIRATION DATE: / PERMIT NO : _ ._�_�_ —__ DATE ISSUED: -_ �_L� ___ , BY: (1 ) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL �I`' _G-J�* '� - AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY RE LiREMENTS. APPLICANT . I 1/ISI AME _ �_.. -1- uTi 55 CIT MON CONTRACTOR 5AMi _ _ -------------------------- NAME ADDRESS CITU PRONE �fl M PLANS BY ._ ._,. — NAME ADDRESS CITY PHONE ESTIMATED IMPROVEMENT TOTAL VALUATION ( 'COST): $ -- FOLLARS -- - - FOR OFFICE USE. , 11MIN. (2) EXCAVATION DATA- 0.02 X s STREET DESCRIPTION PROGRESS & INSPECTION STATUS NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY TYPE LENGTH WIDTH DEPTH ITEM & QUANTITY _^ L- / 11 rL £�� ! STREET 1 � OPEN D INSP l iV � r� TF 1 I / � P► lJ�--R-� E'r10N D U E ESTIMATED STREET OPENING DATE: ' ` ^ - S ESTIMATED STREET CLOSING DATE: / E �i STREET (3) SECURITY NO. -' Bab W% SECURITY AMT.: $ CLOSE SURETY CO.: p-_L�r.r�—+G.�:�n _ -- _: :r i /___ FINAL CERTIFIED CHr.0 H CASH U SONb O (4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL �- SPECIAL PROVISIONS CONDITIONS FEATURES; EXCAVATION LOCATION AND EXTE T y 1 ( L 1 I 1 I - 1 CURB - ' `� — — _ •" '- iJ - _ W 1 1 -CURS 14 , I - - - - - - - - -- - - - - - — ^1 1 I I (S) NOTE THE CITi TIGARD DOES NOT. HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE RIGHT-OF-WAY JURISDICTION IS THAT OF WASKINGTON COUNTY OR THE STATE OF CRE30N THE APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURITIES, TO COMPLY WITH ALL PERTINENT LAWS AND CONSTRUCTION SPECIFICATIONS PE.ITINENT TO CONDUCT OF THE WORK, AND 7'0 SAVE HARMLESS THE CITY AND E..APLOYEES AGA ST ANY INJ Y OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS. I - APPLICANTS SIGNATURE: DATE S f �.I 1 �� mow APPLICATION — STREET IMPR( ":MENT/EXCAVATION COPY TO; o [] (WHITE,)-FILE ORDIN, CE NO. 74-14 ❑ IBLUE) -INSF. ❑ (YELLOW) -OTHER AGENCV (INSTRU^.TIONS ON SEPARATE SHEET) 0 (PINK) -APPLICANT APPROVED © APPLICATION NO.: NOT APPROVED ❑ CITY OF TIGARD, OREGON FEE AMT.: s PEN ING FEE. PMT. ❑ CITY HALL RECEEPT NO.: _�— PFNDINGSECURITY ❑ PUBL IC WORKS DEPA R TMEN T BY_---.—. -__ DATE-—1 I _ _ _ _ — _ — _ _ — _ w _ PENNING AGENCY "OK" ❑ Application and Progress Record MAINTENAIVCE BOND PENDING INFORMATION ❑ FOP STREET IMPROVFMENT/EXCAVATION AS REQUIRED u ANNUA-- (' PEND,NG VARIANCE ❑ EXPIRATION DATE: PERMIT NO . __-- ---- - DATE ISSUED: �__._l�__..I --___-. , BY: .---_-- (1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL - - AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS. .APPLICANT NAME A[)DAESS CIT V PHONE CONTRACTOR ---- NAME CITY PHONE PLANS BY -- -- -- — — -- -- - -- 'NAME ADDRESS CITU PHONE ESTIMATED IMPROVEMENT TOTAL. VALUATION ( COST). $ DOLLARS (2) EXCAVATION' DATA: FPR OFFICE USE: _ l'MIN. _ o.ocXs__ _ =s SrREET _ _ DESCRIPTION PRCGRESS & INSPECTION STATUS NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY TYPE LENGTH WIDTH DEPTH ITEM & QUANTITY -- STREET — OPENED — INSPE - R TION E _. U E ESTIMATED STREET OPENING DATE--_____`_L_..._—..1 _ S T —— - ESTIMATED STREET CLOSING DATE: ___ ___.____.) L _ _- F. D _ (3) SECURITY NO. __� SECURITY AMT.: $ �-�w— —CLOSED SURETY CO.: FINAL .J-"� I_ j� _ CER-r1FIED CH€CK ❑ CASH (3 BOND a INSPEC. ' P& 10 Rf r. (4) PLOT PLAN. INDICATE SITE.'ERTINENT PHYSICAL — -� SPECIAL PROVISIONS/CONDITIONS: FEATURES; EXCAVATION LOCATION AND EXTENT. 1 1 I 1 `I �5) NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO 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 r'OMPLY 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. APPLICANISSIriNATURE -- _ DATE I t C. Y OF i IG ARD z _Amount dollars Name__-� C� . . • �� Cash M.O. 91dg \u St.Opng. Bus.lic. Plyg. - Fubctns. - Bike Lic. U Elctl. [� Copies Sew.Serv, [7 Sewer Filing Fine$F. - LJ Assmt. El Other - Zoning h r for: Permit # CITY OF TIGARD Y.MIICMC�•A IMTIMO O*T•TIfIM�•- 14979 OREGON AUTOMOBILE INSURANCE COMPANY HOME OFFICE . PORTLAND,OREGON 97207 Bond No. SB 30635 KNOW ALL MEN BY THESE PRESENTS, That ivc, MARY. CHRISTEN, as Principal , and OREGON AUTOMOBILE INSURANCE COMPANY, a corporation organized under the laws of the State of Oregon, and authorized to transact the business of surety in the State of Oregon, as Surety, are held and firmly bound unto the CITY OF TIGARD, OREGON, in the just and full sum of THREE HUNDRED TWENTY-FIVE AND NO/100 DOLLARS, (5325.00) , for which suer, well and truly to be paid, we bind ourselves , our heirs , executors, administrators, successors and assigns, jointly and severally, firmly by these presents. Sealed with our seals, and dated this 3rd day of September, 1976. THE CONDITION OF THIS OBLIGATION IS SUCH, That, WHEREAS, the said Principal has applied to the City of Tigard, Oregon for a Street Improvement/ Excavation Permit, said work to be located at 11040 S. W. 119th, Tigard, Oregon, in accordance with Ordinance No. 47-14 of the City of Tigard, NOW THEREFORE, If the said Principal shall conform to the condition of said permit and restore said Public road to as good or better condition as existed prior to said work, and maintain such work in such good condition for a period of one year, then this obligation shall be void; otherwise this obligation shall remain in full fort andeffect , R Christen, r ncipel-�' y� OREGON AUTOMOBILE INSURANCE C011PANY i BY: Helen L. Codliver, Attorney-in fact m cm c CL a K . O O 0 m S- V V u_ CL CL c 4j 14 -Fa i —,Ve \' W r fn z < w i o r-) ! f- iI a to i • I