9337-9339 SW HILL STREET FILE NO. rJ2'`11
HILL ST. - 9337-.19 STR. OPN. PERMIT
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APPLICATION - STREET liAPR( -MENT/EXCAVATION COPY TO:
[] IWHITC) FILE
ORDINA.,CE NO. 74-14 ❑ (BLUE) -INSP.
❑ (YELLOW) OTHER A%:Rllcv
(INSTRUCTIONS ON SF_PAPATE SHF'E'r)
[� IPIN K) APPLICANT
APPF70VED APPLICATION NO.:NOT APPROVED ❑ CITY OF T[GAR0. ORLISON FEE AMT.: f
PENDING FEE PMT. ❑ CITY HALL RECEIPT
PENDING SECURITY ❑ PUBLI ./ORKS DEPARTMENT By - -- IL- - - - - - - - - - - - - - - -
PENDING AGENCY -OK" Q Application and Progress Record
MAINTENANCE BOND
PENDING INFORMATION i� FOR STREET IMPROVEMENT/E;(CAVATION AS REQUIRED
ANNUAL
PENDING VARIANCE n EXPIRATION ATE:
PERMIT NO.: .. 2� r r� � `'
DATE ISSUED: BY:
;_�._��__ ,
( I) APPLICATIUN I H -REBY MADE TO EXCAVATE FOR AND INSTALL
-k 5 � AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT �i�� �1� 1 i C)D Il Sy r Lcyt-4t
NAME ADDRESS CITY -' . /PHONE
CONTRACTOR_
y� NAME ADDRESS CITY i PHONE
PLANS.ANS B Y —
NAF E ADDRESS CIT PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S --
DOLLARS
(2) EXCAVATION DATA: FowoPFlcE- sll ---�_— WHIN- "
L
_ 0.02x !_ ,��C •- =f_ ._
STREET _ _ DESCRIPTION PROGRESS & INSPECTION STATUS-
NAME SURFACE CUT CUT CLOT MATERIAL INSTALLED ITZM DATE REMARKS/TYPE RY
_ TYPE LENGTH WIDTH DEr"TH ITEM A QUANTITY
L �. �_ �,_ ri !TREES' —
A 011310
INSIDE
R Ib
Q
rSTIr.'ATED STREET OPENING DA-C: _. .S / L S _
T
ESTIMATEL STREET CLOSING DATE:
STREET .__..._
(3) SECURITY NO. _- -}�-�- SECURITYAIAT.: S ____._._ CLOSE
SURETY CO : y !A--�U�'n FINAL
CERTIFIED CHECK CASH ❑ MONO U INSPEC. —.
(4) PLOT FLAN: INDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS /CONDITIONS.
FEATI'R-b. EXCAVA TION LOCATION AND EXTENT.
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(5) NOTE THE CITY OF T'IGARD 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 COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE FIARMLESS THE (-ITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMA;E WHICH MAY RESULT FROM APPLICANTS ACTIONS
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APPLICANTS SIGNATURE ���i 4 DATE
City of Tigard
INSPECTION REOUEST
for
INSPECTION TIME : PERMIT NO.:
DATE: / /' DATE ISSUED:__1__L
OWNERS NAME :
ADDRESS -L .
C0NTRA�.T0R
TEST: Air 0, Water p , Vieual�, Laboratory
RESULT* Approved �, Disapproved
O , pending p
SKETCH:
1
INSPECTOR DATE
NOTE : Attach SuPPlemental test dote herst:01