9490 SW SATTLER STREET FILE NO. -( -<
SATTLER 'STREET-9490 STR. OPN. PERMIT
CIT. X MAW
EXPENDITURE REIMBURSEMENT REQUEST
This form is a multi-use form. Where appropriate receipts must be attached.
Documentation is important for all purposes. Staple documentation to form.
VENDOR NO: ` DATE; 4
PAYABLE T0: L!d F 1 e1r �jc'vF\o b�1 �ti Requested by:
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MISCELLANEOUS (parking, books, subscriptions, dues, memberships. etc_. ) :
Date Description Account No. Amount
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GENERAL MEAL EXPENSE:
'Date Description _ _ Amount
Account Number to be charged: W Total _
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MILEAGE:
Date Description: (Include end/start readings and total miles) Amount
Account Number: _ Totalmiles x$.21 =
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APPROPRIATION BALANCE: AS OF: Signature
APPROVALS (if $25.00 or under may be reimbursed thr,)ugh petty cash) :
(up to t500.00)Section Manager _— Purch. Agent
($500.01-$5,000.00)Dept. Head/Purch. Agent
APPLICATION -- STREET IMPRC V1ENT/EXCAVATION COPY TO:
❑ (WHITE)-FILE
ORDINANCE NO 74-14 [] (YE W)-INbP.
rN
(INSTRUCTIONS ON SEPARATE SHEET) [-jK)-OTHER AGFNCV
(BLUE)-APPLICANT
�►
APPROVED APPLICATION NO.
NOT APPROVED ❑ CITY OI' 'I'IGARD, OREGON FEE AMT. f / s/=/
PENDING FEE, PMT. 13 CITY HALL. RECEIPT NO.: T
PENDING SECURITY ElPUBLICWORKSDEPARTMENT BY_(�F, _ DATE S_ _ ..
PENDING AGENCY "OK" ❑ Application and Progress Record
MAINTENANCE BOND
PENDING INFORMATION ❑ FOR STREET IMPROVEMENT/EXCAVATION AS REQUIRE13
ANNUAL
PENDING VARIANCE ❑aa p� EXPIRATION DATE:
PERMIT NO : _ �Q !/ —._Q.Q_ . DATE ISSUED: 7 12.1 �� � BY:
1 I APPLICATION IS HEREBY MADE TO EXCAVATE FOR AND INSTALL
_ AS DESCRIBED HEREIN, IN FULL
A�CCORDANCEWITH CITY REQUIDRE�MyElN/TSy.
4'4-
APPLICANT '?.L)
NAME
C lIry NONE
CONTRACTOR- / I _ __ '` '41
—-------
NA E', - - ADDRESS CITY PHONE
PLANS BY I` _ �I _—
NA-9�E_ ___._ —_..- -.__ADDRESS CIV--V—_ PHONE
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S Li� —__—
_ __ DOLLARS _
(2) EXCAVATION DATA: —__--- -_— - -~-- FOR OFFICE ys
0.04 X f
STREET _ DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM AI QUANTITY
STREET —
IMSP..C-
R TION
.� E --
U —
ESTIMATED STREET OPENING LATE, S
ESTIMATED STREET CLOSING DATE: ... _ 1___.__ L E
— STREET
(3) SECURITY NO. SECURITY AMT.: S��'_. CLOSEri
SURETY CO.: _ _ FINpi.
CERTIFIED CHECK �� CASH U MOND !7INSPEC. GY
(4) PLOT PLAN: INDI ZATE SITE PERTINENT PHYSICAL SPECIAL PROVISIONS /CONDITIONS '
FEATURES; EXCAVATION LOCATION AN XTENN
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INS, tpjKv 1 `
( 1 1 -
I
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(5) NOTE THE CITY OF TIGARD DOES NOT, HEREBY, GRANT PERMISSION TO APPLICANT'S TO CONDUCT WORK WHrRE
RIGHT-OF WAY JURISDICTION 15 THAT OF WASHINGTON COUNTY OR THE STATE OF OREGOA,
THE APPLICANT AGREES TO DEPOSIT THE REQUIRED SECURITIES, TO COMPa Y WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS TILE CITY AND
EM,'LOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS
APPLICANTS SIGN ATURE' � /LC/fj C DATE
CITY OF TIGARD — RECEIPT OF PAYMENT REC NO. ('30101666
CHECk ()MOUNT 130. 00
NAME: MARINER DEVELOPMENT CASH i�MOLJNI . 00
ADDRESS: PAYMENT DATE:. 12-02---88
PO BOX 1368 BLOCk-. NO/ADDR:
BEAVERTON, OR 97075 SATTLER ST. STREET OPEN
PURPOSE OF PAYMENT AMOUNT PAID PURPOSE OF PAYMENT AMOUNT PAID
----------------------------- ----------- --------------------------- ------------
CUSTOMER DEPOSITS 125.00 PUBLIC IMPROVEMENT PERMITS 5. 00
TOTAL AMOUNT PAID — — — — 130. 00
I mmmsegme Mir r
MARINER DEVELOPMENT, INC,
PO BOX 1388 628-9029 4082
BEAVERTON, OR 97075
1/S.7
1230
Day to t
�e
Wder,
Dollar,
Z/
Flrsl 11,44e Bank
of Oregon,N A
IN stab W8shinglon Square BranCh
P.O.Box 2=7
Ban Tiga(d.0 91223
For q�lp
11800 408 2111 1: 10 3000 L 2 31: 5 2 7 00 31,130 0111
INSPECTION NOTICE r.
City of Tigard E mig Department
P.O. Box 23397 I
Tigard, Oregon 97223 �; v
`Phone: 639-4175
Type of Inspection
Date Requested
( --
Time A.M.._____P.M.
Address ,' l�11 _� cs(tL _ Permit #
Owner-_ Lot #__
Builder
The following Building Code deficiencies are required to be corrected: r
Presented to F1 Approved
Inspector tapproved
Date /2 -� . �8' /-.30�ik.-
CALL FOR REINSPECTION
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