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M
I fit) INSPECTION NOTi'CE
City of Tigard Building Department
12420 SR Main St.
Tigard Omgwi 97223
Phone: 639-4171
Type of Inspection
Date Requested Time.—
Address
Permit
Owner Lot,
luilder
The following Building Code deficiencies are required to be covrected:
Presented to eApproved
Inspector
-70
LDisepprovod
Date
CALL FOR REINSPECTION
0 YES El NO
SEWER PERM IT N� 28434
'-- DATE
Uf
Soworago Agency CITY OF > ' �- �•i�% _
of Washington County
PHONE i 2;2,—
OWNERs
.ems.e'er �� r
OWNER' S ADDRESS:______=.__ "'
TYPE OF INSTALLATION,
[I BUILDING SEWER ❑ LINE TAP AND BUILDING SEWER ❑ LINE TAP
TYPE OF OC�UPANCYo
❑ COMMERCIAL
❑ EXISTING ❑ SINGLE FAMILY
❑
❑ MULT . RES. ❑ IN JSTF'IAL
FIXTURE UNITS j ' DWELLING UN ITS
ADDRESS OF STRUCTURE .
Permit Conditions: The applicant agrees to cocply with all rules and regulIt ations of the Unified
the PermiNumber. The
Permit
+ please refer
to (permit$eWeagegency. calling
inspection, The tolAmtpaid
exp res onehundred twenty t120) from date a
fee. :onnection charge, line tap fee and/or otter charge) wi'+1 be forfeited 1f the permit expires.
side
er
The Agency doesnot at thguaranteremen�t givenacLheflnstellerthe tshellion fprospectwthreetfeetsin alltdireche tions
is not located shall
from
mitthe
distance+ante". If
no and so located,
Agency the
ill instainstaller
lateral. a "Tap and Side Sewer'
Per
the
FEESt
PERMIT 7E1_
s -----
CONNECTION CHARGE —
LINE TAP INSTALLATION - �5GED BY
OTHER
TOTAL
APPLICANT _ DATE
SEWER PERMIT W 28434
ADDRESS OF STRUCTURE _— _______-- - QUARTER
TAX MAP = �- TAX LOT SECTION —
LOT —_ BLOCK - -- OF
APPROVED BY DATE ISSUED BY DATE OF—ISSUANCE
-+
D.U. ' S REMARKS ` "`
V
BUILDING RECEIPT
NAME: DATE:
S
1
ACCT. M DES'-mIPTION AMOUNT
10-432 Building Permit Fees = `_
10-431-600 Plumbing Permit Fees s
10-431 501 Mechanical Permit Fees s
10--23G--St;1 State Building Tax
10-433 Plans Check Fee
30-•443 Sewer Connection (20X)
30-202 Sewer Connection (80x) s •� 1��-�
30-444 Sewer Inspection
51-448 Street System Dev. Charge (SDC) :
52-449-610 Narks I System Dev. Charge (PDC) f
52-449-620 Parks II System Dev. Charge (Mr)
31-450 Storm Drainage Syst•.,-,, Oev. Chrg (SSDC) f _
10-230-505 TRFD (95x) f
10-478 TRFD (5X)
10-230-506 Washington County Fire N1 (95X) _
10-478 Washington County Fire M1 (5X) :
10-220 Amart/Wedgewood S ��
TOTAL
(bs/1214P)
Y
APPLICATION — STREET IMPROVEMENVEXCAVATIONf(BLUE))
PY TO:
(WHITE)-FILE
ORDINANCE NO. 74-14 (YELLOW)-INSP.
(PINKOTHER
(INSTRUCTIONS ON SEPARATE SHEET) A
PPL CANTNCV
APPROVED APPLICATION NO.:
NOT APPROVED f] (%I I Y 1)}' I IC;AItD, UREGUNFEE AMT.: >T_I f 0.�0 —.
PENDING FEE, PMT,
C;1HA[.<. RECEIPT NO.: _r -r
PENDING SECURITY [] PUBLICWORKSQEPARTMENT l
BY
PENDING AGGIICY 'OK" ❑ Application and Progress Record MAINTENANCE BOND
PENDING IN' ORMATION ❑ FOR S'fREET IMPROVEMENT/F-XCAVATION AS REQUIRED I,.
ANNUAL f"
PENDING V. ?:ANCE ❑ 1-XPIFtAT10NOAT E:
PERMIT NO.:���_� _�_ _�___-_____
DATE ISSUED: _..__—_L_�1_�__._ , BY:
(1) APPLICATION IS HEREBY MADE TCU EXCAVATC rOR AND INSTALL
__ AS DESCRIBED HEREIN, IN FULL ACCORDANCE WITH CITY REQUIREMENTS.
Leo M. Grahek IU4:5 SW Fable 'Ar(ry t _� Ti and OT�,jonn — _
NAME CITY p
CONA + 1�asteSA [ueciari Co. T Newberg, —Ct 538-2312
�1TRAC OR ACITY
"—`moi+€
PLANS BY Burton Fm ineerin, V 3011 Tigard Play,a Y rigard, CIE 639-6116
NAIVE �- .At ORESS CITY
ESTIMATED IMPROVEMENT TOTAL VALUATION ( COST): S —AjL`) >V•'JU
DOLLARS
(2) EXCAVATION DATA: i FOR aIrril
�7ab. s 1$0.O0 cnIIN.
o.U4 X S
STREET _DESCRIPTION PROGRESS & INSPECTION STATUS
NAME SURFACE CUT CUT CUT MATERIAL INSTALLED ITEM DATE REMARKS/TYPE BY
TYPE LENGTH WIDTH DEPTH ITEM IR QUANTITY
STREET
:I'liu ALL(,, s t Unc. Pi �r I INYION
U
-.^ E
ESTIMATED STREET OPENING DATE: Z. Q S
ESTIMATED STREET CLOSING DATE:
/ TE
D
STREET
(3) SECURiT NO. �`-' F — SE�CURjTYAMT: S ____:" CLOSED
SURETY CO.: ', I tl S1c --v! v, FINAL —i
NSPEC.
CERTIFI[O CHECK H rJASH U SONO'" !Lisp
(4) PLOT PLAN: INDICATE .SITE PERTINENT PHYSICAL �- SPECIAL PROVISIONS/CONDITIONS:
FEATURES; EXCAVATION LOCATION AND EXTENT, i� All work sltall conforru to that
J �
Which is described on the attc;he
1 I 3
construction plan (risked 4/1U tl5
by the af.ursaid enuineerinA firm).
..!I
I I I I
-
(S) NOTE THF_ CITY OF TIGARD DOES NOT, HCREBY, GRANT PERMISSION TO APPLICANTS TO CONDUCT WORK WHERE
RIGHT-OF-WAY JURISDICTION IS THAIOF WASHINGTON COUNTY OR THE STATE OF OREGON.
THE APPLICANT AGREES TO DEPOSIT THE FIEQUIRED SECURITIES, TO COMPLY WITH ALL PERTINENT LAWS AND
CONSTRUCTION SPECIFICATIONS PERTINENT TO CONDUCT OF THE WORK, AND TO SAVE HARMLESS THE CITY AND
EMPLOYEES AGAINST ANY INJURY OR DAMAGE WHICH MAY RESULT FROM APPLICANTS ACTIONS.
APPLICANTS SIGNATURE DATE