12485 SW MAIN STREET FILE NO. U3-1`1
MAIN ST. - 12485 STR. OPN. PERMIT
lay 1.5, 190
7i�,,ard Car ;dash
12435 T! ^.ain St.
77223
�"entl!2:ne�n:
Please find Oncl po!
Yourr t:xul,v,
Jahn S. Ilawnan
.Sort. Flop" 'livigion
DSII;p i r
x"nr,losurP
REQUISITION
CITYOF TIGARD
WASHINGTON COUNTY,OREGON DATE
CHECK ONE: M I want to buy the following. Please rc-'arch. Foward to Pur-
chasing Coordinator.
f�:] I have researched the following (attached quote information) .
Please issue a Purchase Order. Forward to Purchasing Coor.dinato'r.
C1 I have ordered the following. Please issue a confirming Purchase
Order. Forward to Purchasing Coordinator.
ED I have received the following. Please make payment, Forward
to Accounting. Received: ,
Date Initials
P.O. #
DATE REQUIRED SHIP TO
OTHER INFORMATION
ACCOUNT # QUANTITY DESCRIPTION (Please explain thoroughly) UNIT PRICE TOTAL PRICE
�.
J
TOTAL tdIO lNT $
RECOMMENDED VENDORS
DEPARTMENT HEAD APPROVAL Distribution:
FINANCE DIRECTOR APPROVAL White - Pur. Coord. or
(for 600 Accounts over $2500, and all 700 Accounts) Accounting
Yellow - Department Copy
+" Aty of Tigard
INSPECTION REQUEST
for
INSPECTION PERMIT NO.
DATE : !V ZA12 DATE ISSUED: _ .1__�.
OWNERS NAME ' .1 wo,-e,
ADDRESS : _ 1w _.r1-_`
CONTRACT 0 R :__-12�1-._— lqt�, 0—n
TEST'. Air ❑, Water ❑ , Visual.4 , Laboratory ❑
RESULT: Approved ❑ , Disapproved til , Pending ❑
SKETCH: Stu e -s�:C� waUf z�.7rt_� S
INSPECTOR DATE
EN0TE Attach supplemental test data ter ;r-
APPLICATION — STREET IMPR' 'EMENT/EXCAVATION COPY TO:
ORDIN_.,ICE NO. 74-14 0 �BLUE)-INSP.
O (YELLOW)-OTHER Ar3ENCY
(INSTRUCTIONS ON SEPARATE SHEE
T
D IPINK)-APPLICANT
APPROVED APPLICATION NO.:
NOT APPROVED ❑ CITY O •1 IGARD, OREGON FEE AMT...3�q-�'�f 3
PENDING FEE. PMT. ❑ CITY 11ALL REC PT NO.:
PENDING SECURITY ❑ PUBLIC WORKS DEPARTMENT BY_4-10
DATE___-
PErOnING AGENCY "OK" ❑ Application and Progress Record
RIAINTENANCE BOND
PENDING INFORMATION FJ FOR STREET IMPROVEMENT/EXCAVATION AS REQUIREO
ANNUAL
PENDING '✓ARIANCE ❑ E—X—P—IRATION
-DATE: /
PERMIT NO.: w5� 7 DATE ISSUED: _ ��_�— [ (iY:
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
S DESCRIBED HEREI 'a, IN FULL ACCORDANCE 111fJTH CITY REQUIREMENTS.
APPLICANT T(� _ IC� — _
_ C11
PH sNE
CONTRACTORAPDRFISS
PLANS BY /� C c �1 /7S — _
NAME ADORCSS \ cnvy --- -� HONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): E
DOLLARS
(2) EXCAVATION DATA: FOR OFFICE USE. 'M IN
— 0.02X !_
STREET _DESCRIPTION PROGRESS & INSPECTION STATUS
NAME TYPE F3Y SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS
TYP_ LENGTH WIDTH DEPTH ITEM d QUANTITY ITEM
111111 T ale ��ti� 1,�0�- ( STREET
ClEg ED
It INSP C-
R TION
E _.r
Q
U _
ESTIMATED STREET OPENING DATE _!,�� t' 7Y ES v
ESTIMATED STREET CLOSING DATE — -
T
.____ _ L J l / E
D
�C;rlJ STREET -
(3) SECURITY NO. . --_ SECURITV i M"::- CLOSE
SURETY CO.: FINAL f
E
CRTIFIED CHECK G CASH eOND n INSPEC.
(4) PLOT PLAN: INDICATE SITE PERTINENT 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 COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINST20141"s-
N.IURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
l
(tPPLICANTS SIGNATURE ti{iK ./,�4,,r— DATE `' F� lsr—_
APPLICATION -- STREET IMPR =MENT/EXCAVATION COPY TO:
n (WHITE) - FILE
ORDINHIJCE NO. 74-14 (BLUE) -INSP.
n (YELLOW) -OTHFR AGENCY
(INSTRUCTIONS ON SEPARATE SHEET) (PINK; APPLICANT
'PPROVED (] APPLICATION NO.: _
.UT APPROVED El CIIN' UI' IIGARU, OREGON FEE AMT.: : —._.
PENDING FEE. PMT. ❑ CI N' HA[.L RECEIPT NO.: _
PENDING SECURITY ❑ PUBL IC WORKS DEPA R TMEN T BY __ DATE L
PENDING AGENCY ''OK'' Application and Progress Record
MAINTENANCE BONG M _
PENDING INFORMATION LJ FOR STREET IMPROVEPAENT/EXCAVATION AS REQUIRED n
ANNUAL.
PENDING VARIANCE ❑ EXPIRATION DATE: /
PERMIT NO -- DATE ISSUED .�� ._.__�---_-_-- BY: — _-- ----- -------
(1) APPLICATION !S HEI- EBY MADE TO EXCAVATE FOR AND INSTALL
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLI,, ANT
NAME - - - AUOR[5: - s CITY PHON
CONTRACTOR _
----- NAME - _ ---------- ApORkSS C��-- �_--_- - PHONE
PLANS BY
- NAME ADDRESS
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $
DOLLARS
2 EXCAVATION DATA:
FOR OFFICE USE: owlN.
( 1 002x • =s
STREET _ ___ _ DESCRIPTION _ PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
—_ TYPE LENGTH WIDTH DEPTH _ ITEM !!1 QUANTITY _
STREET
P Al? h f
R TIION 1 k' —( i .
EQ
U � —
ESTIMATED STREET OPENING DATE: —__Lr S
ESTIMATED STREET CLOSING DATE: / L E
D
(3) SECURITY NO. __ SECURITY AMT: S __-_ _ CLOSEDD
SURETY CO.- , _ FINAL
CERTIFIED CHRCK 0 CASH ❑ MOND ri INSPEC.
(4) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL. SPECIAL PROVISIONS/CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTENT.
I I 1 1
i
1 1 1 1 -
r
(5) NOTE: THE CITY OF TIGARD DOES NOT, HEREBY, GIFANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT-OF-WAY JURISDICTION IS IHAT OF WM,SHINGTON COUNTY OR THE STATE OF OREGON.
THE APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURITIES, 1'0 COMPLY WITH ALL PERTINENT I.AWS AND
CONS'TRUCtION SPECIFICATIONS PIcRTINE'NT 1'0 CONDUCT OF THE WORK, AND TO SAVE HARMLESS Ti-IF_ CITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE OHICH MAY RESULT FROP4 APPLICANTS ACTIONS.
APPLICANTS SIGNATURE __.� DATE
CITY OF TIGARD 12420 S.W.MAIN—TIGARD,OREGON 97223
RECEIPT
DATE:
AMOUNT: $
NAME: 0A 1-1) 4)
CASH:
ADDRESS: '6'BECK:
'-
OF
FOR-
ACCT. ,I PERMIT! A-M—RCHARGE
SEWER BILLINGS 40-364
BUSINESS LICENSE 05-331
PLUMBING PERMIT 05-332
MECHANICAL PERMIT 05-332
BUILDING PERMIT 05-333
SEWFR CONNECTION 40-363
SEWER INSPECTION 40-365
SYSTEM DEV. CHARGE 25-366
PARK DEV. CHARGE #1 30-367
PARK DEV. CHARGE #2 30-368
ZONING ADJU MENTS 05-362
TOTALS
RECEIVED BY-
PERMIT NUMBERS ASSIONED.
NumberAmount Number Amount Number Amount
•
RECEIPT 2459