Permit CI TY OF T SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT #: SWR2004 -00403
DATE ISSUED: 6/10/2005
13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171
PARCEL: 2S112CD-11900
SITE ADDRESS; 15976 SW 77TH TERR ZONING: R - 12
SUBDIVISION: HAMBACH GROVE LOT: 017 JURISDICTION: TIG
Project Description: New SFA sewer connection.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1.0
TYPE OF USE: SFA NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Owner: FEES
LEGEND HOMES Description Date Amount
12755 SW 69TH
SUITE 100 [SWUSA] Swr Connection Fee 6/10/2005 $2,500.00
PORTLAND, OR 97223 [SWINSP] Sewer Inspection Fee 6/10/2005 $35.00
Phone: 503 620 - 8080 Total $2,535.00
Contractor:
REQUIRED ITEMS AND REPORTS
Phone:
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 -001Q through O^ 952 - 001 -0100. You
may obtain copies of these rules or direct questions to OUNC by calling 566-246-6699 or 1 -800 . -2344.
Issued by: , P��� Permittee Signature: a d .
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.