10650 SW 121ST AVENUE FILE NO. 3 Z-l
121ST AVENUE - 10650 STR. OPN.. PERMIT
CITY }I: TIGARD
EXPE14DITURE REIMBURSEMENT REQUEbT
I
This form is a multi-use form. Where appropriate receipts must be attached.
Documentation is important for all purposes. Staple documentation to :Form.
VENDOR NO: DATE:
PAYABLE T0: �-1E1 Mme► }Ivi Requested by: -
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MISCFLLANEOUS (parking, books, subscriptions, dues, atemberships, etc. ) :
Date DescriptionAccount No. Amount
PIC UK% � �r��c� � I O -Z.Z0 30Q�oo
A% c�321 2
_ ori �1L1� �601033c�5 _
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GENERAL MEAL EXPENSE:
-Date Descri )tion Amount
Account Number to be charged: Total
MILEAGE:
Date Description: (Include end/,.,tart readings and total miles,' Amount
I Account Number: Total_ miles x$.7. 1
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APPROPRIATION BALANCE: _--AS OF: Signature
APPROVALS (if $25.00 or under may be reimbursed througT% petty cash) :
(up to $500.00)Section Manger Pu -ch. Agent
($500.01-$5,000.00)Dept. Head/Piirch. Agent
mss.
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September 5 , 1989
CITY OF TIGARD
Public Works Department
13125 SW Hall Blvd .
Tigard , OR 97223
Re : Deposit Refund on Permit #321-89
Dear City of Tigard :
Please refund the $300. 00 deposit on record for permit #321-
89. The work has been completed as required .
Make check payable to Heidi A. Martin at the address below.
Should you have any questions, give us a call .
Thank you.
Sincerely,
GLENBOROUGH MANAGEMENT CORPORA'T'ION
it
HEIDI A. MARTIN
Property Manager
HAM/dps
ti N 8 �y�J
Community UG461141nwltM
6700 SW 105th AVENUi #31 1 0
BEAVERTON,OREGON 97005
503 641 8035
APPLICATIGN --- 'STREET IMPRO` 1ENT/EXCAVATIO►d COPY TO:
ORDINAI,.,E NO. 74-14 (WHITE)-FILE
(YELLOW)-INSP.
(INSTRUCTIONS ON SEPARATE SHEET) (PINK)-OTHER AGENCY
C) }b(BLUE.)-APPLICANT
APPROVED
APPLICATION NO.: _��7
NOT APPROVED CITY OF TIGARD, OREGON "."
FEE AMT. f
PENDING FEE. PMT, [] CITY HALL _
RECEIPT' NO.:
PENDING SECURITY p PUBLIC WORKS DEPARTMENT P-f
__.-_ DATE..
PENDING AGENCY '*OK- C] Application and Progress Record - -
PENDING INFORMATION ❑ AS REQUIRED
MAINTENANCE BO D M
FOR STREET IMPROVEMENT/EXCAVATION —�-
PENDINGVARIreNCE ❑ ANNUA'-
EXPIRATI N
- _ DATE./ --
PERMIT NO : DATE ISSUED c7 B1
_
----"'r'
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FO, 4ND INSTALL
- A' DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT .K�er,roNAq� KIL 4o-700 SW iOSI��*311yc«�e� k.,y os- w-(�1-80�
AA1'11 n ME ADDRESS CITY �— PHONE
CONTRACTOR ntt C C�,AC►� L SW I �Ir (9t�`�-7L_7 24$-740�I
NAME ;ODRESS CITY' ---�
PHONE
PLANS BY _ <�
AME
AWA ES • CITY HONE
1 !�
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ � zDo _
DOLLARS
(2) EXCAVATION D.AT- : from OFFICE USE: 1-10 �►cMIN,
40.04 X s___ OD •• = f
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED
TYPE LENGTH WIDTH DEPTH ITEM d QUANTITY ITEM DATE REMARKS/TYPE BY
_ y STREET
w Pr
I
SP -- --- --
TION
E ---- —
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U
CST IMATED STREET OPENING DATE:�� / / / E!
CSTIMATED STREET CLOSING DATE: / / T ----- --
E
-- -13► SECURITY NO. SECURITYAMT.: t .BOO. S'1REETCLOSSURETY CO. FINAL `r
CASH -to a Ch
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS / CONDITIONS.
FEATURES: EXCAVATION LOCATION AND EXTENT.
L t I — -_lLSct /7
X418
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--V�o 7;�
OTE THE CITY OF TIGARD DOES , 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 COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PCHTINENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY AND
EPIPLOYEES AGAINST ANY INJUR', OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS
J
APPLICANTS SIGNATURE DATE
T
d�
bL bb-6£9(£09) LZZL6 UOf3eJO'PJB :6££Z X09'O'd"PAI9 IIDH MS 9Z 6£6
HEIDI A. MARTIN 171
EXPENSE ACCOUNT
8700 S. W. 105TH NO.311 041-8035 L. 3;M9
EAVERTON, R 87 05 ='
r ,
PAY TO THE
`ORE:
OR OF V r .
Inas
CrossLand
Savings
BEAVERTON OFFICE
12M a.W.FARMINGTON RD.,BEAVERTON,OREGONanoa
1: 324070596i: L055509L92li' Oi7l -