Permit CITY TIGARD SEWER CONNECTION PERMIT
' �� I DEVELOPMENT SERVICES PERMIT #: SWR2005 - 00104
� SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 3/23/2005
PARCEL: 2S103BC
SITE ADDRESS; 12240 SW ALBERTA AVE ZONING: R -4.5
SUBDIVISION: CANOGA PARK LOT: 005 JURISDICTION: TIC
Project Description: Connect existing house to sewer service. Reimbursement District #30 fee on this date.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Owner: FEES
MICHAEL CONN
12240 SW ALBERTA Description Date Amount
TIGARD, OR 97223 [SWINSP] Sewer Inspection Fee 3/23/2005 $35.00
[SWUSA] Swr Connection Fee 3/23/2005 $2,500.00
Phone: 503 -590 -6566 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 Utiljty Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You
may o in copies of the e rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -234.
A I Permittee Signature:
Iss ed by: g
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.