Permit CITY OF TIGARD SEWER CONNECTION PERMIT
.71 a COMMUNITY DEVELOPMENT Permit #: SWR2010 -00125
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 09/23/2010
Parcel: 2S103CB00100
Jurisdiction: Tigard
Site address: 13035 SW 121STAVE
Subdivision: WILLAMETTE Lot: 1
Project: Lancaster
Project Description: Sewer connection for existing residence.
FEES
Owner:
LANCASTER, MICHAEL T AND PATRICIA Description Date Amount
13035 SW 121ST AVE Sewer Connection Fee 09/23/2010 $4,100.00
TIGARD, OR 97223 Sewer Inspection - Residential 09/23/2010 $35.00
PHONE: 503 - 322 -6727 Reimbursement District Revenue 09/23/2010 $17,167.71
Contractor:
PHONE:
FAX:
Type of Use: SF
Class of Work: ALT
Install Type: Line Tap and Building Sewer
Fixture Units:
Number of Dwelling Units: 1
Total $21,302.71
Required Items and Reports (Conditions)
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the 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 a copy of the rules
or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. •
•-i
Issued By: Permittee Signature: , air. `
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.
i --f a ,-
$1111 Commwi Dew f:_ . _
Ti c. n I: D: Reimbursement District Payment Worksheet
Cr ;"`t S (._)F Iylp- n i
Planning /Engineering to complete:
2
Site Address: /3O � s SL.) 12-1 S1'' .
Parcel No.: A5 i t3 3 C tS - 0.21 I ll p
1 1 i (�7 'I1
Reimbursement District No.: $ 1 Amount Due: ,0h I 3 /7) i i )
�y P-124,11A419--D
Date: ` 2 - J ! J By: s.-..
Note: Amount due is as of date shown above.
Deferred Accounts:
Name:
Phone Number:
Legal:
Amount paid: $
Remaining to .e paid; deferred amount: $
Building Division to complete: Jl.J2 ,,zD / 0 _ 0 0 l c2 --S
Reimbursement amount paid: $ / ? 14 7. 2/
Received by: i
i avve7e}i_e__
Return completed worksheet with copy of receipt to planning /engineering permit technician.
Planning/ Engineering to complete:
Enter "paid" parcel tag.
Enter "deferral" parcel tag, if applicable.
Route copy of receipt and parcel information printout to Finance Department.
I: \CURPLN \Masters \ReimburseWorksheet.doc 2/23/07