Permit r „
CITY OF TIGARD SEWER CONNECTION PERMIT
- COMMUNITY DEVELOPMENT Permit#: SWR2014-00019
13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 07/07/2015
TIGARD Parcel: 1S134DA01800
Jurisdiction: Tigard
Site address: 10757 SW NORTH DAKOTA ST
Project: TASTO Subdivision: NORTHERN PINE Lot: 6
Project Description: New SF.
Contractor: Owner: TASTO, RUSSELL J & NICOLE K
1401 E 8TH ST
NEWBERG, OR 97132
PHONE PHONE:
FAX:
FEES
Description Date Amount
Specifics:
Type of Use: SF
Class of Work: DEM
Install Type: Line Tap and Building Sewer
Fixture Units:
Number of Dwelling Units: 1
Total $0.00
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 952-001-0090. You may obtain a copy of the rules or direct questions
to OUNC by calling 503. 32.1•:7 or 1.800.332.2344.
I
Issued By: 4/ Permittee Signature: /-94/- r,"/(1 / n -77l)
Call 503.639.4175 by 7:00 a.m.for the next available inspection date. `-�T'
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.
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
II Request Permit Action N 0 P�„
TIGARD 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
'1'0: CITY OF TIGARD
Building Division Services Supervisor VOII
13125 SW Hall Blvd.,Tigard,OR 97223 3/a51/9i l/a'
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor 'K—Staff
(ch ck,,nt)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
./.../17..../.."............."
City/State/Zip:
Phone No.:
PLEAS TAKE ACTION FOR THE ITEM(S) CHECKED (1):
CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: SGJ CS III--(XX L 9
Site Address or Parcel#: /0 7 S 7 Et ) Aid rill 4.kc ► C71
Project Name: ./45
Subdivision Name: N,}rf cv—A1 /1/'t Lot#: 6
EXPLANATION: 5 c,,,--e d- j a-c, ;-9- S CU kc d 1 4- MO VI I is /vat
fuee- -4 aS cal c r+.c`_ C_J-c_e4 -4t Pa20 i`i ~ Ue)aa Li cif/0 i y,
Signature: ,......-.1 - Date: 3//)./
y
Print Name: Bret :teAl J;�&I'J
Refund Policy
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80°o of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80°'0 of the land use application fee for issued permits.
d) not more than 80°o of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80 of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2-4 weeks for processing refunds.
I OR OI I I(;I. I 'I O\I.1
Rte to S s Admin: Date in , B , Rte to B1d t Admin: Date P7419M 13_,(„1x,,,
Refund Processed: Date , By ,,,.. Invoice Processed: Date 1y
Permit Canceled: Date 3/25/jv By ..... Parcel Tag Added: Date By
Receipt# Date Method Amount$
I:\Building\Forms\RegPermitAction.doc Rev 05/25/2012