12045 SW SPRINGWOOD DRIVE ILE NO.
SPRINGWOOD DR. - 12045 STR. OPN. PERMIT
1
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APPLICATION — STREET IMPR' CMENT/EXCAVATION COPY TO:
ORDINr„+CE NO. 74-14 �j (WHITE)-FILE
❑ (BLUE)-INSP.
(INSTRUCT10fV ; ON SEPARATE SHEET) ❑ (YELLOW) -OTHER AGENCY
❑ (PINK)-APPLICANT
APPROVED
NOT APPROVED ❑ CITY OF TIGARD, OREGON. APPLICATION NO.:
FEE AMT.: :
PENDING FEE. PMT. ❑ CITY HALL RECEIPT NO.: _
PENDING SECURITY ❑ PUBLIC WORKSDEPARTMENT BYe DATE_ _q _/_7 / 77
,� �
PENDING AGENCY "nK< _❑ Application and Progress Record — — — — ” — — — — —
PENDING INFORMAIION ❑ FOR STREET IMPROVEMENT/EXCAVATION MAINTENANCE D oar
PENDING VARIANCE ❑ ANNUAL IJ
EXPIRATION DATE:-7xC Nf, Z4+I"
PERMIT NO.: _ „r!
— — DATE ISSUED: __1.. LScZ BY: -- — _--
(1) APPI (CATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY F:EQ REMENTS.
APPLICANTiIA t��._)
1.
ADDR SS CI,1 �---=--J---` 1=rS�
C-04TR-ACTOR __ %" � PHONE
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NA E ADDRESS
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ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S
(2) EXCAVATION DATA: FOR OFFICE ultis: -- ` -- r3m —"
STREET DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED "'—'
TYPE LENGTH WIDTH DEPTH 1', SM AQUANTITY ITEM DATE REMARKS/TYPE BY
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ESTIMATED STREET OPENING DATE: _ �� IE —
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ESTIMATED STREET CLOSING DATE:__- E —
(3) SECURITY NO. D — ---
S CURRY M1, STREET
SURETY CO.: _ � �' — CLOSED
--- CI rIFIED cliECK _ FINAL
-__-_ _ CASH ❑ _BOND INSPEC.
(4) PLOT PLAN: INDICATE E:TE PERTINENT PHY-%CAL ~�
FEATURES; EXCAVAT'0N LOCATION AND EX11i,NT. SPECIAL PROVISIONS/CONDITIONS:
1
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-CUR% —
NOTE: ',HE CITY OF TIGARD DOE,( NOT, HEREBY, GRANT PERMIRRION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT-OF-WAY JURISDICTION IS THAT tJr WASHINGTON COUNTY OR THE S1 ATE OF OREGON.
THE APPLICANT AGNEES TO DEFOS t THE REQUIRED SECURITIES, TO COMP, Y WITH ALL PERTINLNIT LAWS AND
CONSTRUC'YION SPECIFICATIORIS PERTINEN-' TO CONDUCT OF THE WORK, AND 1'0 SAVE HARMLESS THE CITY AND
EMPLOYEES AGA INET ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPL1':: %NTS ACTIONS,
APPLICANTS SIGNATURE:
—� I Dk,TE _- >
APPLIcknON - ET'•iEET IMPRr• -MENVEXCAVATI,314 COPY TO:
ORDINm_CE 'I'' 7^-14 ❑ (WHITE)-FILE
❑ (BLU E) INSP.
(INSTRUCTIONS ON SEPARATE SHOE ! ❑ (YELL.OW)-OTHER AGENCY
❑ (PINK)•APPLICANT
,ROVED LJ APPLICATION NO.:
NOT APPROV-0 0 CITY Or •riGARD, OREGON FEE AMT.: f
PENDING FEE. PMT. ❑ CI"rY HALL RVCL IPT NO.:
PENDING SECURITY ❑ PUBL IC WORKS DEPA R TMEN T BY DATE--,L-.-- /
PENDING AGENCY "OK" ❑ Application and Progress Record
PENDING INFORMATION O FOR STREET IMPROVEMENT/EXCAVATION MAIASE NE ED s--
ANNUAL
PENDING VARIANCE ❑ EXPIRATION DATE:
PERMIT NO.: _ ---- , DATE ISSUED — -�--�— "---- BY: -- --, -- ---
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
AS DESCRIBED HEREIN. IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
APPLICANT NAGE-- ADD149311— —
CONTRACTOR
- - ---- -
E ADORElS CITEPLANS BY ___ _
A ADDRESS � CITY PRONE
ESTIMATED IMPRO'VEMCNT TOTAL VALUATION ( COST): E
OMIN.
(2) EY.CAVATION DATA: FOR OFFICE USE:0.02 X f
STREET _ 'DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT—T CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
-__ TYPE LENGTFt '..I DENTH ITEM S QUANTITY
-- -- -�
STREET
REED
I N 5 ION 7 AP 9�Cc�r<tvz` /.
E'TION
ESTIMATED STREET OPENING DATE: ,t_ /
ESTIMATED STREET CLOSING DATIL:_ / / T
E
(3) SECURITY NO. STREET
—__ SECURITYAMT.: $ _ CLOSE
_
SURETY CO.: ` __ FINAL
CERTIFIEDCHECK n_ CASH U SOIahu INSPEC, f�"..�T-r
(4) PLOT PLANINDICATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS/CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTENT.
1 1 1 I
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1 NOTE. THE CITY OF IIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANTS 1-0 CUNI]LICT WORK WHERE
RIGHT-OF-WAY JURISDICTION IS THAT OF WASHINGTON COUNT Y OR THE STATE OF OREGON
THE APPLICANT AGREES TO DEPOSIT THE REQUIRED SECUA ,TIES, TO COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF 1 HE WORK, AND TO SAVE HARMLESS THE CITY AND
CMPL.OYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RIE!ULT FROM APPLICANTS ACTIONS.
APPLICANTS SIGNATURE _ DATE i /
I I
CITY OF TIG/ . .:D �
Date 1#7� � Amount
` A-V--
-V _ dollars
Na��-�-`�-������ � Cash
M.J. _
Chec�c�
Addressl_!1 —rte,--
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Bldg. ❑ St.opng. ❑ Blis.Lic. ❑
Plbg. ❑ Pubctns. - ❑ Bike Lic. ❑
Elctl. ❑ Copies ❑ Sew.Serv. ❑
Sewer ❑ Filing ❑ Fine&F. ❑
Assort. ❑ other - ❑ Zoning ❑
For.
Permit #
-- -- CITY OF TIGARD
SY— MNI T0�11N0..T.tloNf.Y
163r. 2
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City of Tigard
INSPECTION REQUEST
for
IINSPECTION TIME: PERMIT NO. :—._ –
DATE: 7 ) DATE ISSUED :--Ll—
OWNERS
SSUED :_ , /OWNERS NAME :
ADDRESS: QT Z! a' r►7 ZI---
C 0 i J T R A C TO R : V !=#-A—AJ
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TEST : Air 0, Water(] , Visual X, Laboratory ❑
RESULT. Approved , Disapproved C , Pending p
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SKETCH:
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hH SPR/,V6-Wor,D DR
INSPECTOR DATE
COtB : Attoch supplementat test data beret!]