Permit ,, CITY OF TIGARD SEWER CONNECTION PERMIT
1N
a ' COMMUNITY DEVELOPMENT Permit#: SWR2016-00050
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 03/02/2016
Parcel: 25111 BD01700
Jurisdiction: Tigard
Site address: 9930 SW MURDOCK ST
Project: Murdock Street Partition Subdivision: ALDERBROOK FARM Lot: 5
Project Description: Connect existing house to sanitary service. Septic tank to be properly decommissioned.Reimbursement district 27.
Contractor: Owner: RYAN, SCOTT PATRICK
1711 NW 100TH ST
SEATTLE,WA 98177
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 03/02/2016 $5,100.00
Sewer Inspection-Residential 03/02/2016 $35.00
Type of Use: SF Deferred Reimbursement District Fee 03/02/2016 $12,171.66
Class of Work: ALT
Install Type: Line Tap and Building Sewer
Fixture Units:
Number of Dwelling Units: 1
Total $17,306.66
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 503.232.1987 or 1.800.332.2344.
Issued By: `%,� /�� ! rmittee Signature:
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Call 503. 5 by 7:00 a.m.for the next available inspection da .
This permit card shall be kept in a conspicuous place on the job site until completion o the project.
Approved plans are required on the job site at the time of each inspection.
City of Tigard . COMMUNITY DEVELOPMENT DEPARTMENT
P . Reimbursement District Payment Worksheet
I I, ,, f.; ) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
This completed worksheet is to be submitted along with payment for sewer
connection and plumbing permit application by expiration date below.
ENGINEERING TO COMPLETE:
Site Address: 9930 Sin/
Reimbursement District #: a 7 Parcel #: 72///&iO/ /)O
Amount Due: $ / 2,/2/, 6.6 Amount Due Expires On: fl - 4 /.6
Applicant: Daytime Phone:
n Sewer Loan Processed (journal entry to follow for payment)
Deferred Accounts (if applicable): X
Owner: Daytime Phone:
Legal Description:
Amount To Be Paid: $
Amount To Be Deferred: $
❑ Deferral Agreement (signed prior to completion of worksheet)
By: Date:
BUILDING TO COMPLETE:
Reimbursement Amount Paid: $ /,?, 171. 64 Receipt #:
SWR #: Sw/040l(o—Ow SCS PLM #: Pa-19-0/62-oo/og
Enter parcel conditions in Accela (check all that apply):
Enter "paid" condition.
❑ Enter "deferral" condition, if applicable.
By: s' �` � Date: 5/2/41
Attach this worksheet to sewer permit for records scanning.
I:\Building\Riembursement Districts\ReimDistPaymentWorksheet_021014.docx