7185 SW SANDBURG STREET EII,E NO. ���`
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SANDBURG ST. - 7185 STR. OPN. PERM
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`"fav la, 1980
Vrademark 4omas
5070 SW Nall
Beaverton, OR 97005
,e* Pe fund - Street Openin., T)epogi t
(lent 10"m I
Please find enclose,] it clie.c,- in t"O a:roount of $4'10. wbi.ch if; n.. refund
(in your street openinn
Yours truly,
John B• HaR an
Supts Engrs Division
artolow�'a
REQUISITION
WASHINGTON COUNTY,OREGON DATE
CHECK ONE: C I want to buy the following. Please research. Foward to Pur-
chasing Coordinator.
I:.::] I have researched the following (attached quote information) .
Please issue a Purchase Order. Forward to Purchasing Coordinator.
M I have ordered the following. Please issue a confirming Purchase
Order. Forward to Purchasing Coordinator.
CJ I have received the following. Please make payment, Forward
to Accounting. Received: ,
Date Initials
.�.. P.O. #
DATE REQUIRED SHIP TO
OTHER INFORMATION
ACCOUNT # QUANTT.TY DESCRIPTION (Please explain thoroughly) UNIT PRICE TOTAL PRICE
TOTAL AMOUNT -- - $
RECOMMENDED VENDORS -�
DEPARTMENT HEAD APPROVAL Distribution:
FINANCE DIRECTOR APPROVAL White - Pur. Co--rd. or
Accounting
(for 600 Accounts over $2500, grid all 709 Accounts) yellow - Department Copy
MWAW
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APPLICATION - STREET 11%4PRC HENT/EXCAVATION COPY TO:
ORD11" qCE NO. 74-14 ❑ ( LUEJ --FILE
I] (BOLUE)•INSP.
❑ (YELLOW)-OTHER AGENCY
(INSTRUCTIO, ON SEPARATE SHEET) ❑ (PINK) -APr LLIIC��ANT
APPROVED ( APPLICATICN NO.: --!—
_
NOT APPROVED ❑ CITY OF TIGARD, OREGON F F E AMT.: S l 9*0—_
PENDING FEE. PMT. L] CITY HALL RECEIPT NO.: 3'
PENDING SECURITY El PUBLIC WORKS DEPARTMENT BY ,--Y/0'1�' DATE_ g L l7�
- - - - - - - - - - - - - - - -
PENDING AGENCY "OK" 0 Application and Progress Record MAINTENANCE BOND M
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS HEQU FED o
ANNUAL ❑
PENDING VARIANCE ❑ EXPIRATION DATE: 17
_—
PERMIT NO.. /60-7, 7 DATE ISSUED: L 1 �Lr/_._ _ , BY:
(1) APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY/REQUIREMENTS,
APPLICANT vµf2_—7140 tom,_Tjj 1p't AE�) d_ poN��9n4_ Z����4Lf
M E �/ ADDRESS CI'1 Y PHONE
CONTRACTOR IINWc 0-0—Wil hl6me1 GM.°O �,L'� �BwW--- _B 4_'�'ew9/
NAME ADDRESS ���/� 1 CITY PHONE
PLANS BY_ P4 ���--- � �" M- _------ A0/7� - iZZI_ -� S7
NAME ADD SS CITY HONE
*ep .O
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): $ -
DOLLARS
(2) EXCAVATION DATA: -- _ FOR OFFICE usg �� MIN`. -
_ 0.02 X s —_Z—=-
STREET DESCRIPTION PROGRESS & INSPECTION STATUS_
NAME SURFACE CUT CUT T CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
-
---TYPE LENGTH WIDTH DEPTH ITEM A QUANTITY _-_�-
STREET
4' OPENED
INSP C-
E TION -�
Q
U — - ---
ESTIMATED s'rREET OPENING DATE:— ,-- S
ESTIMATED STREET CLOSING DATE:__ ( E _
ST'REF_T
(3) SECURITY NO. —. SECURITY AMT.: �'-�"' _ CLOSED
SURETY CO.: —___— _ _ - FINAL
CERTIFIED CHECK CASH ❑ BOND ( INSPEC.
(4) PLOT PLAN: INDICATE SITE PERTINR'NT PHYSICAL -z SPECIAL PROVISIONS/CONDITIONS
FEATURES: EXCAVATION LOCATION AND EXTENT.
1
(S) 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 T'O CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEES Ar.A1NST ANY INJURY OR MAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
APPLICANTS SIGNATURE: _ �- DATE �/ '/
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12
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