12525 SW 68TH PARKWAY-1 FILE NO.,
68TH AVE. - 12525 STR. OPN. PERMIT
C11 . DHIGAMM
EXPENDITURE: REIMBURSEKE NT REQUEST
L' 1
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: 'I- - % t>t�
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PAYKBLE TO: c� }i<. t l_LUMaC�i�c lc �4�'.- Requested by:
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MISCELLANEOUS (parking, books, subscriptions, dues, memberships, etc.):
Date Description Account No. Amount
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'47 ��FUV,1� of �T _T �►�� �h�r 1500:_
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GENERAL MEAL EXPENSE:
.Date Descri tion Amount
Account Number to he charged: _ Total
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MILEAGE:
Date Description: (Include end/start readings and total miles Amount _
Account Number: _ Total miles x$.21 r _
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»/ APPROPRIATION BALANCE: AS OF: Signature
APPROVALS (if $25.00 or under may be reimbursed through petty cash) :
(up to $500.00)Section Manager Purch. Agent
($500.01-s 5,000.00)Dept. Head/Purch. Agent �_
i
Pacific Christian Counseling Center
12525 S.W. 68th Avenue • Tigald, Oregon 97223 + (503) 639-9523
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"larch 30, 1930
Mr. John Hagrnun
City of Tigard
P.O. Box 23397
Tigard, OR 97223
Re: Permit #;283-88
3oId Deposit
Dear Mr. :iagman:
This letter will serve as our request for final insrNe-ction of the
sidewalk and driveway approach at 12525 S.W. 68th Avenue, Tigard,
for the I)urpose of our bond release. Pacific Christian Counseling
Center posted bond in the anount of $1,500.00 on March 1.8, 1988.
Please Contact us if you require any additional information.
Sincerely,
PW_'IFIC CHRISTIAN COUNSELING CENTER 4 /''4''�
Glenda Raulerson c
Office Manager \v�,S e 1
Encl: Cbpy of. permit �SSur e �ztl -
COW
Post-II'routlnp redusel pfd 7661 �\rA O L1
�,doT
Please ROUTING - REQUEST �\Yc.
1EAD Tofid GL -�` �'2 v e- 1 ego
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1:11 HANDLE �� � ir4 >w�•, ,.,C
0 APPROVE ii -et
end
r� FORWARD �`` [~�')if 1 /7 t 'c ee
LJ j3ETURN Jt7 t- e-
KEEP OR DISCARD !
E] REVIEW WITH ML
Dole
From
APPLICATION -- STREET IMPR EMENT/EXCAVATION COPY TO:
NO
ORDIN.,NCE: NO. 74-14 WHITE)-FILE
YELLOW)•(NSP.
(INSTRUCTIONS ON SEPARATE SHEET) ❑ (PINK)-OTHER AGENCY
(BLUE)-APPLICANT
APPROVED APPLICATION NO.: 319
NOT APPROVEDCI I Y O I IGARD, OREGON c�0
❑ FEC AMT.: f—� : m
PENDING FEE. PYT. ❑ CI I'N' IIALl, RECEIPT _?0 7 z
PENDING SECURITY ❑ PUBLICWORKS DEPARTMENT BY –_'7�� _ _DATE _LIS —f ,
PENDING AGENCY "OK" ❑ Application and Propess Record
MAINTENANCE BOND #
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS REQUIRED L2
ANNUAL U
PENDING VARIANCE ❑ EXPIRAT ON DATE: NC 4'.'2. _
PERMIT NO.: DATE ISSUED: _ _1' s'c BY:
(1) APPLICATION/JS HEREBY ADE TO EXCAVATE FOR AND INSTAL(_ �D RFK D�'JVEL<L¢
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT _ G[ '1C:_SLt�Is17A11! 6x/u A.►c, ,L!/ 1e /25zsS,ul. �6� v _�l� X639-7.523
NAME ADDRESS fN CITY 9722;3 (HONE y[�
CONTRACTOR �Q/�Ell(1�,-.jFi./13 r�.t Lc.Q, /-S/ZS _S,W, /2 Yr�q 11L237_,`JJ�j
,NtA�M..E, , ADDRESS � CITY --�'P ONE
PLANS BY _� -�'L.__
NAME ADDRESS
CY r> CITY
ESTIMATED IMPROVEMENT IMPROVEMENT TOTAL VALUATION ( COST): $
DOLLARS
FOR OFFICE USE
(2) EXCAVATION DATA:
0.04 x s p _.,.=f__� .C�,
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM GATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM A QUANTITY
SYR_EE T
/ LC /�!✓ts• (NSP -
t�r R TION r' Z.P FV ,u .1. .{
E
ESTIMATED STREET OPENING C ATE. –3 �� / / c � E
S
ESTIMATED STREET CLOSING DATE. _ _ I 1 T —
E
D
toa STREET
(3) SECURITY NO. __. . SECURITY AMT S _ "' CLOSED
SURE rY CO.. FINAL
oM doompme CHECN ('ASH •ONO r= INSPECIt
(4) PLOT PLAN: INDICATE '31TE PERTINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS:
FEATURES, EXCAVATION LOCATION AND EXTENT.
all
I 1 C I I _-CTU &w_ AlrAlrj&l4
Al 70
*tom- `I -- — -- - �� 1• - - -
__—
(5) NOTE THE CITY OF TIGARD DOES NCT, 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
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEIES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
APPLICANTS SIGNATURE �` tti� GATE �� �✓ /
JOHN K ZUBER CONSTRUCTION
13125 S. W. 12 4th
TIGARD, OREGON 97223
639-0395
/01 Ir'
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CITYQF TIOAMPO No. 30662
13125 S.W. HALL BLVD.
P.O. BOX 23397 �, Q
TIGARD, OR 972.3 Date.—.�-q-:- L
. r
Name
Address — —
Lot Block/Map Subdivision/Address _
Permit k's Bldg. Plumb Cash Check V
Sewer Other — Othar ec. By
Acct. No. Descriptlon -- 1 J
Amount
10-432_ B,iilding Permit Fees
10-431-600 Plumbing Permit Fees_ —
10.431-601 Mechanical Perrnit Fees
10.230-501 State Bidy. Tax _ —
10.433 Plans Check Fee
30.443 Sewer Connection
30-444 Sewer Inspection
51-448 Street Syst. Dev. Charge
52.449-610_ Parks 1 Syst. Dev. Charge
52-449.620 Parks II Syst. Dev. Charge -- —
31.450 Storm Drainage Syst. Dev. Charge
10.430 Buslness Tax
10-434 Alarm Permit
10-227 Bail
10.455- Fines • TrafticlMisd/Parking __ --
10.230• CPTA Traffic/MisdlVic. Asst.
10.456 Indigent Defense —
30.122-401 Sewer Service/USA -- —
30.122.402 Sewer Service/City 30%
30.123 Sewer Sevice/City Maint.
30.125 Unmatched
31.124 Storm Drainage
4 •47 - t3ancroft Prin. Pymt.
40-471 '— _ Bancroft Int. PyFT
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VP
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CUSTOMER'S COPY 0
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I"I III 1;; 10 1.111 [al':I I1[:R ('OR A RF C[ iP l
NAml Plcto�c . „st�-ati �ouHsell�c� `c,� e.1 DAIF.
A(C I . 11 I Il;i(al I II ION AMUIIN I
to e,
]0 7.2(100
Refundab](, t>erfl)rnl,anct ! ()nci
10 n3")00 in h�rmit5 IIUP Ill
$
10- 4,ri00 Public tit,wc,r flan (.h( ck/Inrpec-_l.ion Lee
10-•43600 Public .toren 13lwi Chock/Lnspection Faze $
10-•43600 Street 1)edi cat i un/fIwh i i c I nit,rmwilioni I er !�
10••43600fit:r'ec�l Ut�r.ntn�� t'armi 1 $
10-•.43601, 5tr•t+et and I rcaf f i( M it k i r,j
2144200 (rest L i(3ht I
10..4„r,; N0. 869426
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_ 1
REGON 1p 00
8 NATIO
9A►NK OF OAEOON
HEAD OFFICE.p0(aTLAND.O
uNITEt� STATE
l�ttch 18
19 asg
Christian C0unselin Center
Pacific �**10 *
PURCHASED BY GAS * * * * IN * tit * tit*
�To THE * * * C11'y OF TI
ORDER OF
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t O�t9� MEi4
NOTIIO � fequlred before ,
Indemnity
,.and meY the event SIGNATUFIE
The purchase o1 en n, will be 111P In
d eAU
eny of11CIN Chep,o1 this Bs
Of stolen11 N Ips(,mUDi CREC.r
CASH 1-. 123000
JER220�: OLL 0099 42L11'
tt•66q�+ 2611 �o
JOHN H. ZUBER CONSTRUCTION 1 o2 yi�-(-Il67S
PROPOSAL 13125 S.W. 124th
AGREEMENT TIGARD,OREGON 97223
639-0395
L,PAA_5 e I 1 it DATIC
To Steve„Peirce Pacific Christian»C,ounpeli A.l , C 03-16- 88
- µ»
......12525........68111 Ave. Turd»..............................._.... . .___»... Tel.....» 639-95'13...._...»........
The undersigned proposes to furnish all materials and perform all labor necessary to complete the following:
SIDEWALKS AND DRIVEWAY APPRON
Sidewalk 4'6” x ill x 75' dille coo �•y _
Appron 4'6" x 6" x 25' `�
_ Additional to driveway 8' x 25' x 6"
Sidewalk to front door 4'6" x 4" x 25'
All of the above work is to be completed in a substantial avid workmanlike manner according to standard
practices for the sum of ,- FW-11—L111 l c Il"Ild ld ;11111 no 1O0 ---_.,:-- --_(: Z )� -)Dollars.
15
Payments will be made each ..._ days as (he work progresses to the ralue of One Hundred 0.29,7,)
per cent of all work cornpieted. The entire amount of contract will be paid within__!—0 _...days alter completion.
Any alteration or deviation from the above specifications involving extra cost of material or labor will be ex-
ecuted only upon written orders for same, and will become an extra charge over the sum mentioned in this contract.
All agreements must be made in writing.
The Contractor agrees to carry Workmen's Compensation and Public Liability Insurance, to pay all Old Age
Benefit and Unemployment Compensation taxes under this contract as required by the United Stales Government and
the State(j) in which this work is performed, and to pay all Sales Tax(es),if any, unon the materials furnished.
Contract-- jo-ha)1. Zu_ber Construction _
Oregon Registered Builder 1143016
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ACCEPTANCE
You are hereb,, authorised to furtish all materials and labor required to complete the work mentioned in the
above proposal, for which the undersigned agrees to pay the amount stated in said proposal in accordance with the
terms thereof.
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