11535 SW 67TH AVENUE i
y •7�h AVE. 11535 STR. OPN. PERMIT
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EXPENDITURE: kEIMBURSEMENT REQUEST
This form is a multi-use form. ahr -e appropriate receipts must be attached .
Documentation is important for all p,irposes. Staple documentation to form.
VENDOR NO: DATE:
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PAYABLE TO: A. CU1°a41 Lis_ or �U, Requested by:
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MISCEL.LAIIF.OUS (parking, books, subscriptions, dues , memberships, etc. ) :
Date Description Account No. Amount
L4�Pc
...n...............................m..r..-.......................................
.-'ENER.AL MEAL EXPENSE:
mate Description Amount
Account Numbet to be charged: _ 'Total
..................... .................a.....■a..•�s..a...........................
MILEAGE:
Date Deecrip�iun: (Include end/start readings and total miles) /mount___
k count ►lumber: Totalmi leg x1. 20 _
b............................................a...........r.......
.........u..w.
APPROPRIATION BALANCE: AS of: _ Signature
APPROVALS ( if $25.00 or under may be reimbursed through petty cash) :
(up to 1500.00)Section Managet Purch. Agent
APPLICATION - S'TRE.ET IMPP 'EMENT/EXCAVATION CCCCyyyO777PY TO:
OR DI N,,NCE NO. 74-14 M I(YELLO •FILE
�[� (YELLOW)•INSP.
(INSTRUCTIONS ON SEPARATE SHEET) L (PINK)-OTHER AGENCY
l (BLUE)-�APPLICANT
APPROVED ep �
ll APPLICATION NO.: _-� O
NOT APPROVED ❑ CITY OF T'IGARD, OREGON FEE AMT.. 3_T♦ yr
PEND NG FEE. PMT. ❑ CITY HALL RECEIPT NO.: _ ZO 4Z Z
PENDING SECURITY Cl PUBLICWORKS DEPARTMENT By 11 '�' DATE_- 2 I `t,/5?7
PENDING AGENCY "OK" ] Application and Progress Record �
MAINTENANCE. BOND u_
PENDING INFORMATION G FOR STREET IMPROVEMENT/E"f'AVATION AS REQUIRED ---
ANNUAL
PENDING VARIANCI_ ) EXPIRATION DATE:
PERMIT NO.: DATE DATE ISSUED: , ^�._��1 � BY:
(1) APPLICATION Ib HEREBY MADE TO EXCAVATE FOR AND
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT
-A+~ NAME5
ADDRESS CITU PH NE
CONTRACTOR______ ___. 5AajN k7
NAME -- ADDRESS CITY CITY ----'���v---PHONE --
PLANS BY_,4Q4} L�'F .___-._l/Z PD�IL I.2>� �__- _____L_Pk•,r Z27 _410.3
NAME A DRESS CSI ♦ P'HONE- -
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $
_.-_�_._. DOLLARS
FOR OFFICE USE: - MIN,
(2) EXCAVATION DATA: 0,04 X S-LA
STREET -T- DESCRIPTION PROGRESS & INSPECTION STATUS -
NAME SURFACE CUT 1 CUT CUT NATER AL INSTALLED ITEM DATE RErAARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM !! QUANTITY
STREET
- _FSTIESTIMATED STREET OPENING DATE: ��ESTIMATED STREET CLOSING DATE: �
9` STREET
(3) SECURITY NO. _ SECUPITY AMT,: $ �[[��� ' ._- CLOSED
SURETY CO.: FINAL
CERT-FIEII CHECK rASH SOLO INSPEC.
(4) PLOT PLANINDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS i CONDITIONS:
FEATURES: EXCAVATION LOLAT'ION AND Y,XTENT.
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(S) NOTE THt: CITY OF TIGARD VOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT OI'-WAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OREGON.
THE APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURITIES, ?O COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TCS CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINSI ANY IN:URY OR DAMAGE WH!CI4 MAY RESULT FROM APPLICANTS ACTIONS.
APPLICANTS AGNA i'IRE�' DATE 0-125 -M
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Name
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Address
Lot
4046h vow
h,OCt, Nfl. Dmoriptlon
1049 r r Amount
.r Ndin Permit Fees
10.4314W PILO pl- no POrmlt Fees_
10.431 1 M anical Pemiit Fees -�
10.234501 Stets 81da. Tax
1".33 M Flan3—C Qk Fee - /) pe-,.,,,,
30443 lower Connection
30444 Sewer ma
pectlon
51-448 Street S at. Dev. Charge `-
52.449-810 Parka I Syst. Dev. Charge
52-449-M Parke it S at. Derv. Charge -
31-450 Storm Dne aEyet. Dev. Charge )`�L1� �/- Nn, tf�',t>
10-430 Business Tax -
10-434 Alarm Permit — 71t,
10.227 BaII ��A 5 �,(ICC+���n
10-455- Fines-Traffic/Mlad/Parking
10.230- C A Traf Ic►MI Nic. Aset.
10- -TadGmint�enae
1rH Sery as/IJSA ,
1 vwlr cel Ity % - -�
- ewer evlpa Ityant. ,
orrA req
naro