Permit 06/20/2006 12:57 FAX 5035981960 CITY OF TIGARD 2J003
111,0 id/U 4/10 / 50 . cCt4
Building Division [i�
p- , A/
Request for Perrnit Action or Refund � - �
JUN 2006
TO: CITY OF TIGARD � , I 1 .
Permit System Administrator U.. : i
13125 SW Hall Blvd, Tigard, OR 97223 B"] L T : flf \7r� T.. HQ n a,
Phone 503.718.2430 Far 503.598.1960 www.tigard-or.gov
PROM: ❑ Owner [/Applicant ❑ Contractor ❑ City Staff
(check one)
REFUND TO: Name:
(Business or individual) \ C,\r c c. N\o (' avA ad rt�ttie
V 0 1 0 Mailing Address: 11 uk i 5 s- v.1. £c& v n k.
7ej crE ? �� / City/State /Zip: - 70,61,/,-k o=ff 9=1-2_23
A/o T /Fy P:yyLL IS Phone No.: ('03�
ere' &Punrd LSO
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED ( /):
CANCEL PERMIT APPLICATION.
• REFUND PERMIT FEES (attach receipt, if available).
• REMOVE CONTRACTOR FROM PERMIT (do not cancel permit).
Permit #: 5%) R tom to 9 ®i 0 7- SEE / — D oa 95/
Site Address or Parcel #: 15 1 3 5 D D - 0 1 ¥{ 0 3
Project Name: 'R21 o ca Q (r x i s t q 5 h K 40 t � y - No / NcRE4se
Subdivision Name: Lot #:
EXPLANATION:
Signature: c a AA cn o ", Date: Q (, /2 O/ rJG
Print Name: a M u cc Z
Er fund Policy
1. The Building Official may authorize tba refund of
a) any fec which was erroneously paid or collected
b) not more than 80 percent of the parmir fee for lulled permits prior to any inspection requests.
c) not more than 80 percent of plan teview fee when an application u canceled before any plan review effort has been expended.
2. Refunds will be returned to die original Payer in tha s method It which payment was received.
1 Ul: c),1111'Llitil O \) 1 •
Rte to Svs Adtnie: Date S1 B /`y Roe to Bl.. Admire Date B •
Refund Processed Date Antall B • '' f - Invoice Processed: Date B • •
Permit Canceled: Date Z76 B ':;' Parcel T Added: Date B
Recei • t #4 -21,' , Date , ffp - Method C G Amount $ .a6 0 ,
\BuilrIMAPorms \RegPermitAction- dg : oc Rev 05/24/06
12- F�'lfNA a ( o o • OD
t ?� e o C")
C ITY OF TIGARD SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT #: SWR2006 - 00107
DATE ISSUED: 6/5/2006
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171
PARCEL: 1S135DD-04403
SITE ADDRESS: 11950 SW GREENBURG RD 150 ZONING: C -
SUBDIVISION: LOT: JURISDICTION: TIG
Project Description: 0.1 edu increase.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 0.1
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner:
FRED ANDERSON FEES
11950 SW GREENBURG RD # 100 Description Date Amount
TIGARD, OR 97223
[SWUSA] Sewer Connection Fee 6/5/2006 $260.00
Phone: 503- 968 -2425
Total $260.00
Contractor:
REQUIRED ITEMS AND REPORTS
Contact #:
Reg #:
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180 days from the
date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee the accuracy of the side sewer
laterals. If the sewer is not located at the measurement given, the installer shall prospect 3 feet in all directions from the distance given.
If not so located, the installer shall purchase a "Tap and Side Sewer" Permit and the Agency will install a lateral. ATTENTION: Oregon
law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through
OAR 952 - 001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344.
Issued by: , Permittee Signature: 36csa oravt. - -
Call 503 - 639 -4175 by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.