Permit •
CITY TIGARD SEWER CONNECTION PERMIT
DEVELOPMENT SERVICES PERMIT #: SWR2004 -00063
` 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 2/11/04
SITE ADDRESS; 14125 SW FERN ST PARCEL: 2S104BC -06300
SUBDIVISION: HULTQUIST PART /MLP2002 - 00009 ZONING: R -
BLOCK: LOT: 001 JURISDICTION: TIG
TENANT NAME: HULQUIST
USA NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Remarks: Sewer connection of existing house to newly installed sewer lateral.
Owner:
FEES
LARRY HULTQUIST
14125 SW FERN ST Description Date Amount
TIGARD, OR 97223 [SWUSA] Swr Connect 2/11/04 $2,400.00
[SWUSA] Swr Connect 2/11/04 $0.00
Phone: 503 -521 -1668 [ SWINSP] Swr Inspect 2/11/04 $35.00
[SWINSP] Swr Inspect 2/11/04 $0.00
Contractor:
Total $2,435.00
Phone:
Reg #:
Required Inspections
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" Perm
/ ,�� Permittee Signature: I. sued by: , i ��; , - A, _ � ! ji , LLi g
Call (503) .39 -4175 by 7:00 P.M. for an inspection needed the next bu Ines ay
CITY OF TIGARD 24 -Hour
BUILDING Inspection Line: (503) 639 -4175
INSPECTION DIVISION Business Line: R (503) 639 -4171 MST
BUP
Received ' 3 ' Date Requested ' I AM PM BUP
Location Suite MEC
41111M4, ,7
Contact Person • � '�• � _ .A, Ph ( . %fir �Z PLM 2 y- 6 8Q (�
Contractor / '� " ' l � r 0 Ph ( ) `7` - 000 c' 3
BUILDING Tenant/Owner ELC
Footing
Foundation ELC
Access:
Ftg Drain ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath /Shear
Int Sheath/Shear
Framing
Insulation
Drywall Nailing
Fi rewal I
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof
Other: —
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Rough -In
Water Service
anitary Sewe
ain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
• . -r:
' PART FAIL
ME ANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough -In
UG /Slab
Low Voltage
Fire Alarm
Anal Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE 111 Please call for reinspection RE: Unable to inspect — no access
Fire Supply Line
ADA
Approach /Sidewalk Date 21 lot ( o q Inspector Crb `'1'M - sA Ext
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL