Permit a CITY OF TIGARD SEWER CONNECTION PERMIT
.7 1 COMMUNITY DEVELOPMENT PERMIT #: SWR2007 - 00103
TIGARD 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 5/2/2007
PARCEL: 2S 102BC - 03500
SITE ADDRESS: 13000 SW WATKINS AVE ZONING: R -4.5
SUBDIVISION: ROSE TERRACE LOT: 002 JURISDICTION: TIG
PROJECT: JENSEN
Project Description: Connect existing house to sewer lateral. Septic tank is to be pumped and filled. Sewer
Reimbursement District fee on this date.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: NEW DWELLING UNITS: 1.0
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Owner:
RON & ERI JENSEN FEES
13000 SW WATKINS AVENUE Description Date Amount
TIGARD, OR 97223
t S . [SWUSA] Sewer Connection Fee 5/2/2007 $2,700.00
)Q7.°11'%‘ WINSP] Sewer Inspection Fee 5/2/2007 $35.00
Phone:
1 Total $2,735.00
Contractor: 8-$C0*
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4.k �+� G
Co ..`\ V � REQUIRED ITEMS AND REPORTS
Re'
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 obt.' copies of these rules or direct questions to OUNC by calling 03.246.6699 or 1.800.332.2344.
sued by: . 6 / Permittee Signature:
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 completio of the project.
Approved plans are required on the job site at the time of each inspection.
05/01/2007 08:53 FAX 503 350 0377 ELLSWORTH ADHESIVES 0002/003
OS /Oj/ .2007. 07 :24 FAX 5035981960 CITY OF TIGARD ( )002
PlumiingPermit 'Application
fort OFFICE'. 1 sl1; ONl) . . ..
ri vrTigttra v7 A.u - 1x/6 3
Daft . Permit No.:
13125 SW flail Blvd., Tigard, OR 97223 Mei Review i
' - Phone: 503.639.4171 Fax: 503.598.1960 Dearmy:. : Maar Permit No.:
Inspection Line: 503.639.4175
r i O n i;1 � Data RaadYlsY• Bee Page Z rtrc
• . - Interact: www,tigerd� 615
.gov Naed/Mnhoa: _ �/ 0 1 I supplementaltetamatie°
TYPE OF WORK. FEE* SCHEDULE . • •
❑ New constructlotl 0 Demolition
for apedallnrornladort use thafW1�
Description
❑ Addition/alteravoa/replacement ❑ Other New 1- w 1- 2flemfl Qty. l a. I Total
- y dwellings (includes 100 ft for each utility connection)
.,,CA•FEGORY' CONS RUG 'ION SFR (1) bath I 24920 •
❑ 1- and 2- family dwelling 0 Commercial/industrial SFR (2) bath 350.00
❑ Accessory building ❑ multi- family SFR (3) bath 399.00
Eech'additional bath/kitchen 45.00
❑ Master budder 0 Other:
Fire sprinkler (_ sq. ft) Page 2
JOB. SITE , AYFORMATION LOCATION ' i. • ` .... ' '
site utilities
Job Site address: 1 30C exec k N."--‘2 ,c., Catch basin or area drain 16.60'
Ciry /St Le /lJ : '' • 0 C 3 Arywcdl, Ieach line, or trench drain 16.60
Suitt:IbldgJapt no.: Project name: Footing drain (no. linear ft.: .. Page 2
•
Cross street/directions to job site: Manufactured homy utilities
• - Manholes 16.60
•
Rain drain connector 16.60
Sanitary sewer (no- linear ft.: ,• ) Page 2
Storm sewer (ao. linear t: ) ' Page 2
n
Water service (no. Weer ft.: „,-)
Sulldivialon: I Lot no.: _ Page 2
--
Tax map/parent °o.; Fixture or item
Absorption valve 16.60
. ' - . -. . DESRIYITON'; OF - WORK . . - , : , 88d�ow preveater Page 2
_) i.rv• - 1` - ' d{•) c'c
i 1' 1 Backwater valve 16.60
' Clothes washer 16.60
Dishwasher 16.60
P1t6PFRTY'OWNER ' 1 p ''PENfr�i1VT.; • Drinking fountain .16.60
Ejectors/sump 16.60
Namc: gU 1,.''_ 4-- b. 4-; - a - � , y.-se -v....- Expansion tank 16.60
Address: 13 C)OC) e E.4-)c45-1 LAS Fixture/sewer cap 16.60
City /State/ZIl': Clot & 0 aa.� Floor drain/floor sink/hub 16.60
Phone: (x203) r- -- CajA1 ' .- Fax: ( ,) T 5 .- - 52-ci I Garbage disposal 16.60
Hose bib 16.60
4 0 'A-t74,..1.4147' ' „ ; 1.1 .:I • 1. ,, , -❑, -PPITVAC)r, 1 -
- Ice maker
Business name:
-
interceptor /grease trap 16.60
Contact name: Medical pas (value: $ ) Page 2
Address: Primer 16.60
City /State/ZIP: Roof drain (commercial) 16.60
_
Sink/basin/lavatory 16,60
Phone: ( ) Fax:: ( ) Tub/shower /shower pan 16.60
E-mail: Urinal 16.60
CON>rIL4ht'T01t Water closet 16.60
Business name: Water heater 16.60
Add Oeler.
City /State/ZIP: Subtotal
Minimum permit fee: $72.50
Phone: ( ) E Fax: ( ) Residential backflow minimum permit fee: $3625
CCB Lie._ Plumbing tic. no.; Plan review. (25% of permit fee) •
- State surcharge (8% of permit fee)
Authorized signature: TOTAL PER/641T FEE
Print name: Date: Mils permit applleal ob expires if a permit is not obtained within
190 days after it baa been accepted as complete.
*Pee methodology set by Trl County Building Industry Seviee Board.
P,Du11dios 1717/06 440 d0z1[oM/WE3)