11485 SW SPRINGWOOD DRIVE FILE W.
SPRINGWOOD DRIVE-11485 STR. OPN. PERUMIT
CIT OF 1'16A- FM
EXPENDITURE REIMBURSEMENT REQUEST
This form is a : ulti use form. Where appropriate receipts must be attached.
Documentation is important for all peirposes. Staple documentation to form.
VENDOR _ DATE:— - z `✓
PAYABLE r0: M � �e �j,_JSeh Requested by:
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rs==v:araae::cs:ca=ecaan-rca==r_._er_eaa r.x_gym=cr car__-ccaaac-acav ar_r_camaacac3a_r.caaccaaam
MISCELLANEOUS (parking, books, suuscriprions, dues, mewl- -ships, etc. ) :
Date Description Acc%)unL 'o. Amtount
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car-a extra-arerrsm sua-_.cr exz�_.a as vaai .a-cascr_aca Baca Ga ereaaaaaa==ea_�c_caaar_-=azar.=
GENERAL MEAL EXPENSE:
Date Description _ Amount
Account Number to be charged: _ _ Total
sr�an-aeaerar aveaanrrssara sa yr rsr earraa as suaae aar:aaaar>rrr as ra=a as as a-xaacaa.aa axea_e
y7LEAGE:
Date Description„ (Include end/start readings and total miles) Amount
Account Number: _ To :bl_ _ miles x5.21 r
.. =
r w.n.nw-await.... ..ylreS.'aC ae'xe r_s.aa=-�-a=aa-[ a...aaca .aac=:.eaaaa.-cs�sr_sa
APPROPRIATION BALANCE: ----AS OF. Signature
APPROVALS (if $25.00 or under may be reimbursed through petty cash) :
(uP to $500.00)Section Manager Purch, Ageni _
($500.01-$5,000.00)Dept. Head/Purch. Agent __
Jo�w .
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RECEIVED
APR 2 41999
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APPLICATION - STREE:T IMPR t MENT/E XCAVATION COPY TO:
ORDINr,NCE NO. 71l-14 ❑ (WHITE)-FI'_E
❑ (YELLOW)-INSP.
1INSTRUCTIONS ON SEPARATE SHEET I ❑ (PINK)-OTHER AGENC
❑ (BLUE)-APPLICANT
APPROVED
APPLICATION NO.-
NOT APPROVED n CITY OF TIGARD, OREGON FEE AMT.. S � za
PENDING FEE PMT, 1l CITY HALL RECEIPT NO.:
PENDING SECURITY p PUBL IC WORKS DEPA R TMEN T By Lc) DATE_ lid l FC`l
PENDING AGENCY OK" ❑ Application at1C) NtOgrf89 RtCOrCI — —
PENDING INFORMATION O FOR STREET IMPROVEMENT/EXCAVATION MAI ASEa QUIRUDOND N
PENDING VARIANCE !-] ANNUAL
-- C EXPIRATION DATE: _
PERMIT NO.: . f.�: � DATE ;SSUED: 3 /S/ g,19
, BY:
O APPLICATION IS HEREBY MADE TO EXCAVATE =OR AND INSTALL
-- �rV, i/I _ AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY ¢UIgE TS
APPLICANT , �_�i �L Vi ��1/�5�1 7 d
NAM ADOM'Ef �� ✓ vim— -.. Z�s
CONTRACTOR �l✓D
lQ �� CITV _NE. 1
AD RES
PLANS BY �—
- -- _-��G___
ADbgE38 ('ITV
ESTIMAI ED IMPROVEMENT TOTAL VALUATION ( COST): _ �%0�_
- DOLLARS
(2) EXCAVATION DATA: FOR OFFICE U E:
-
STREET DESCR,PrION __ PROC,RESS & IN
SPEG ION STATUS
NAME SURFACE CUT CUT CJT T MM7ERIAL INSTALLED -�
TYPE LENC,T/i WIDTH DEPTH_ _ A gUANTITY ITEM DATE REMARKS/TYPE PY
ITEM
' iL't1R�/ ! I fC - - -T �� I STREET "— --- — -
F N D
i INSPEC. `-- - - --
'— R TION
_ - G
- -- U _
ESTIMATED STREET OPENING DATE:-__ / /� / e�3 E.
-- S
ESTIMATED STREET CLOSING DATE: _ T ��— --- —
E
(3) SECURITY NO. SECURITY AMT: S_/e G_v STREET W�
SURETY CO.: CLOSED
FINAL
CERTIFIEDCHECK n - CASH SONO C INSPEC. !—_L
(A) PLOT PLAN: INDICATE SITE PERTINENT PHYSICAL
FEATURES; EXCAVATIGN LOCATION AND EXTENT. SPECIAL PROVISIONS CONDITIONS:
�eK I �N�r� s it
, I
1
4_4
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S NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS -'7 CONDULT WORK WHERE
RIGH'-OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNTY OR THE STATE OF OOEGON.
THE APPLICANT AGREES TO DEPOSIT THE 4EQU1RE0 SECURITIES, TO COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORTS, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY REFULT FROM APPLICANTS ACTIONS.
APPLICANTS SIGNATURE
DATE S �y��►
l��
i'r'y' OF* TIGPiRD F.-FICEIPT Of" 1'1:'.'L 1401. 001i::,; o
I NGWO01.) ST
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PURP(),--E OF P71 IMF f-j I APIC)UN7 PAID PURPOSE OF PAYHEkll
C U`-,T Ci M E R til"F,il-- 17 7
185. 00 PUBLIC IMPROVEPIEN'r
THAW.". YOU
TOTAL AMOUNT Pia I I.,
-------------
MICHApi,BRASlff-RR. 563
KmnERt,Y ANNR BR&STIURR1�)Cl
1,1485 SW SPRINGWOOD 639-8042 19 96.7416/3232
TIGARD,OR 97223
PAY TO
ORDER OFF
$
(50644-4034
-VWtblo P.O.Box 2100
_.W P.^Wiwk On 070762100
FOR
N4! 23274260564-10563