12700 SW PACIFIC HIGHWAY-1 / 12700 SW PACIFIC HIGHWAY
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TRAFFIC IMPACT FEE
Installment Payment Application and Disclosure Statement
In the Matter of the Traffic Impact Fee for —
/14Z – C vfzS/On
Tax Map Z S 1 2 AC Lot Number(s) 701 _ Building Permit # BNFL/-� _
Site Address { 7�f�D S! _PAC IF/C-6" _ Suhdi�ision _ X74
Case File # ti'/R TIF Land Use District
'To Be Billed To: 7' ANION&9YU % CEAlir"AY z I
Address: /a?'/00 .5'&) PAC'ifiC AlY,— -7 QA'
To the City of Tigard:
In accordance with the provision of Oregon Revised Statute 223.208 and Washington County Ordinance
No. 379 which relates to the imposition of a traffic impact fee for the financing of major collector roads and
a.terials of Washington County, I/we HEREBY MAKE APPLICATION AND AGREE, JOINTLY AND
SEVERALLY, to pay my/air traffic impact fee, as has been determined by Wa0ington County Oidinanc,
No. 379 in _—L0 -__semi-annual installments of the amourn financed together with one-half of one year's
interest thereon at a rate of __,L) annual percentage rate on the unpaid amount
owed. The lien date is the first day of the month following the date the application is signed The first
payment is due six months thereafter and at six (6) month intervals thereafter for a period of &�e_�Syears. Each installment payment will include principal and interest.
If I\we neglect or refuse to pay any part of the installments provided herein, including interest, within one
(1) year atter the same shall haw hecome due and payable, then the whole amount of the unpaid
assessment shall become due and payable at once and shall be collected it I she manner provided by law
including foreclosure on the above-described real property.
The traffic impact fee,annual percentage rate of interest( •Q_-%)and finance charges which I/wc- agret.
to pay are as follows:
HIGHWAY TRANSIT
1) Amount of Traffic Impact Fee . $ 39 _ #//0-00 7p>At-
c�At
2) Amount Financed . . . . . . . . . . . . . . . . . . $ 3 •QQ_ •f1Q P�¢w�E,v�
3) Equal Semi-Annual Principal Payments . . . . $ /Z' iP0 /! oo �4M
P ,�,gn
4) Interest on Balance at Rahn of �'1�--% #13
\We understand that the amount owed, as stated above, shall be a lien on the above-described subject
property pursuant to Washington County Ordinance No 379 Section 6 (D) and ORS 223.230
DATED this _1 r day of i I t9�' r
\ i
Signal t1re of Property Owner(s) Signature of Property Owner(s)
STATE OF OREGON ) Name (Please Print): 1 V�h
k IAVA4 P,
Address-,
�
County of Washington ) 1
L
SUBSCR O FD AND SWORN TO BEFORE me this iT ) day of
z."Y 19`11
u 1) JA, r l QIL t•
Notary Public for Oregon
My Commission Expires:
lorm\v,�I�Ud
W W w
CERTIFICATE OF'
CITY OF TI QARD Cff Y4-TWA RD OCCUPANCY
C��
OD
COMMUNITY DEVELOPMENT'[' DEPARTMENT ORIGON F,Lm-'RM I T #. . .
. . DUP91--'b'230
13126SWHWl8lVd- P.O.Box 233,j7,T%pwd,Oregon UFM(603)eOW4176
PARCELr. 2S102Ac---@170J
1 TE ADDREESS. . . I 1270W l3w GAC"iFIc Hwy
ZONINGi CBD
'SUSS IVISION. . . . :
EsLOCI... . . . . . . . . . : LOT', . . . . . . . . .
CL-A,SS '3F WORK. IALT
-0
TYFE DF" USF. . . :Cam
OCCUPANCY (;SRP- "LA2
OCCUPANCY LOAD:i?4
TENANT NAME. . . tCENTURY i.-1 REAL.TY
Coy,vpY_t YA�..Age to offjoffices, t,f-move, add interr ioPars
tition . See note.
TIr. pAIr) 70 .E B .)i A[IRANGEOIEN7'",' HAVE BEEN MARC.
PAID IN INSTALLMENT'(1
Owner I
J PA rERSO14
1j,700 SW PACIFIC HIGHWAY
TIGARD OR 97223
01-lone 01 ('39-31328
Lontractor:
PAC'IFIC WFSTEPN HOMES, INC..
11350 SE 182ND AVENUE
PORTLAND OR 97233
Phone 1'12 052-973b
Req 0. - : 60663
0c--(.-j.tpA)lcy of thp ahc)verpferpjwu- ed bildin;j is hereby given, and c.,ertiflesl
the compli-iim -e with the E;tate ()f ore,gon SpecioaltY COdfli; fOl- the gv-ol-'Pl
I jupakn�,,,yzyl ttncier which the refproncecal permit w-As i sl:AA P c.i-
5
AQN 0
SU 1. 1 0 'TOP
FiRF-bEPA-Rl*MFNT
B U I I,ID I llifif OFF, ` AL
POST' IN CON iPICUOUS PI-PCE
n
Ivis Ptg-TION- WOT-1CE
city of Tigard Building no-1wrtment
73125 Sir Ball Blvd. Tigard. Oregon 97223
Inspection Line (Rec-tl-Phone): 639-4175 BuBineae Phone: 639-4171
Footing p1bg. Underelab mech. Rough-in Appr/Sdul.k
9• p
Found.
Plb To Out Cao Line FINAL:
post./Beam Struct, San. Se er Framing 9'
Post/Beam Mech. Rain Drain
Insulation -Plumb.
Plbg. Underfloor Water Line Gyp. Bd. -Meeh.
Date Requested:-
Timet ___AM PM
Addreaei
L2) — it
Builder:
THE FOLLOWING 0ORRECTI AAE REQt1IRED:
Inspector
�. Dater - A
-_APPROVED DISAPPROVED APPROVED SUBJECT TO ABOVE
Call For Reinsp.
INSPECTION NOTICE
City of Tigard Building Department
P.O. Box 23397
Tig Oregon 9 223
Phone: 639-41715
Type of Inspection 67-�J y vw - -
Date Requested �U Time A.M.-_.__P.M.
Address 1�2 ���� sf ��� Akl/ — - Permit #_'J -�_-
Owner ---- Lot #- - --- --
Builder -----
The following Building Code deficiencies are required to be corrected:
Presented to __ __ -_ -__ /tpproved
Inspector _ - _— [_� Disapproved
T �Date
ALL FOR REINSPECTION
[ YES C_] NO
INSPECTION NOTICE
City of Tigard Building Dcepartasent
13125 SN Ball Blvd. Tigard, Oregon 97223
Inspection Line (Rec-O-Phone)t 639-4175 Business Phones 6:9-4171
Inspection%__. Z� 3,/d
Pr-)tinp /L. Ond1 elab Mech. Rough-in Appr/Sdwlk
Found. Plbg. Top Out Cas Line FINAL:
Post/Beam .7truct. San. Saver Framing -Bldg.
Post/Beam Mech. Rain Drain Insulation -Plumb.
Plbg. Underfloor Nater Line Gyp. Bd. -Hoch.
L _
Date Ragtteetedt_ Times� � pM
Addrsses_ / 0 drmJ 'E;
8u I I d a r t
TRE FOLIAMINO CORRECTI B ARE RA I `y
QU RF.D t
Inepecto s_ Datetbj
`74PPROVED - DISAPPROVED _ APPROVED SUBJECT TO ABOVE
T Cell Pcr Reinsp.
i
Al
TUALATIN VALLEY FIRE & RESCUE
AND
BEAVERTON FIRE DEPARTMENT
4755 S.W. Griffith Drive• P.O. Box 4755 • Beaverton, OR 97076• (503) 526-2469 • FAX 52()-2536
September 9, 1991
Chet Antonsen
Pacific Western Homes, Inc.
1350 S.E. 122nd
Portland, Oregon 97233
Re: Century 21 Real Estate Office
12700 S.W. Pacific Hwy.
6089A-172-003
Dear Mr. Antonsen:
This is a Fire and Life Safety Plan Review and is based on the
1988 editions of the Uniform Fire Code (UFC) and those sections
of the Uniform Building Code (UBC) and Uniform Mechanical. Code
(UMC) specifically referencing the fire department, and other
local ordinances and regulations.
Plans for the above captioned project are conditionally
approved subject to the City of .Tigard Building Department
requirements and the following conditions:
1 . Approved Plans on Jab Site_ One set of approved
plans bearing the stamps of the building department
issuing the construction permit and this office must
be maintained on the project site throughout all
phases of construction and must be made available to
building and fire inspectors for reference during
required construction inspections . UBC Sec. 303
2 . Required Occupan_y Cert.ifi.cate. Prior to the use and
occupancy of the project (space) , a certificate of
occupancy or other written instrument of approval
must be obtained from the building department issuing
the construction permit . UBC Sec. 307
"14'ork(ng"Smoke Detectors Save Lives
s
Chet Antonsen
September 9, -99.1
Page 2
If I can be of any further assistance to you, please feel free
to contact me at 526-2502. .
Sincerely,
Gene Birchill
Deputy Fire Marshal
GB:kw
cc: Tigard Building Departme;it
r
INSPECTION_ NOTICE
City of Tigard Building Departrent
13125 ON Ball Blvd. Tigard, Oregon 97223 +.
Inspection Line (Rec-O-Phone)e 639-4175 Business Phone: 639-4171
inspectian:� `� ---- --- ' —
Footing Plbg. Underslab Hoch. Aongh-in Appr/Sdwlk
Pound. Plbq. Top Out Cas Line PINALt
Post/Beam Struct. San. Seater !taming -Bldg.
Post/Beam Mech. Rain Drain Insulation -Plumb.
Pibq. Underfloor Water Line Gyp. Rd. -Hoch.
Date Requeetedt ^7_. TiAss _AH _ PM
/
Address: it # J U
Builder:
THE FOLLOWING CO IONS AAS REQUIREDs
Inspector:_- _ ^ ._ Date% ---
PROVED DISAPPROVED APPROVED SUBJECT TO ABOVE
Call For Reinep.
C11Y OF TIGA RD AC461D BUILDING PERMIT
7
COMMUNITY DEVELOPMENT DEPARTMENT ORS PURMIT #. . . . . . . : BUP91-0230
13125 SW HWI Blvd. P.O.Box 2M97,Tgmd,Oregon 07223(6W)&W-4175 ; 77
63,-)—4�1. 7 1 DATE ISC.31JED: 09/03/91
�:�ITE ADDRESS. . . : 121700 :3W PACIFIC HWY PARCEL: 210-'AC-0170J
SUBDIVISION. . . . : ZONING: CBD
BLOCK. . . . . . . . . . : LOT. . . . . . . . . . . . .
REISSUE: FLOOR EXTERIOR WALL CONSTRUCTION—
CLASS OF WORK. :ALT FIRST. . . . :`412 s N: S: E: W:
TYPE OF USE. . . ,COM SECOND. . . : Sf PROTECT OPENINGS?---—
TYPE OF CONST. :5N THIRD. . . . : Sf N- S: E- W:
OCCUPANCY GRP. :B2 TOTAL--.-----: 2412 s ROOF CONST: F 1 RE RE-T?
OCCUPANCY LDAD:24 BASEMENT. : s AREA SEP. RATED:
`73TOR. : 1 HT. : 14 ft GARAGE. . . : Sf OCCU SEP,. RATED:
BSM-r'?:N MEZZ?:N READ SETBACKS—----- REQUIRED--------------------
ET
I-LOOR LOAD. . . . :50 Psf LEFT: ft RGHT: ft FIR SPIKLJ )
4 SMOK r, T. . :N
DWELLING UNITS: FRIV r : ft REAR- ft FIR ALRM:N HNDICP ACC:N
BEDRMS; BATHS: IMP, URFACF: PRO CORP:N PARKING:
VALUE. $ - 6000
Remarks : Convert garage to offir-es, r-emoyp, add irtterior, partitions. See note.
Owylet-.- ---------------------------------- FEES
J PATERSON type amot-trit by date r-eept
12-700 SW PACIFIC HIGHWA` PRMT $ 56. 50 JLH 08/E7/91 ='1671=:2
PLCK $ 36. 73 JI..H 08/27/91 216722
TIGARD OR 97'2'23 FIRE $ .22. 60 JLH 08/27/91 216722
639-38"S 5PICT $ 2. 83 JL.H 08/27/91 216 7 22
TIF' $ 1,346. 00 JLH 09/0:/91
PRMT $ 56, j0 JL.H 09/03/91
-
PAC lFIC WESTERN HOMES, INC.
13750 SE 122ND AVENUE
PORTLAND OR 97233
i-oyie #: .252-9776 t 1523. 16 TOTAL
Req #. . : 60663 REQUIRED INSPECTIONS
This persit is issued suhjtc� to the regulations contained in the F r-a mi Ti q I ri s p
Tigard Municipal Code, State of Ore. SpeTialty Codes and all other lnsf.ilaticm Irlsp
applicable laws. All work will be done in accordance with Gyp Board Iticip
approved plans. This pet-sit will expire if work is not started Sl.tsp Ceilnq Insp
within 180 days of issuance, or if work is suspended for Rore Final Inspect ion
than 180 days.
p,�3 v-m i t t e P S j q n a t A r-e -
Issi.ted By :
Call fot, inspection '�39-4175
CITY OF TIGARD ..� ,/`1
Building Permit No.
COUNTYWIDE -�/i,,
TRAFFIC IMPACT FEE Planning File No.
PAYMENT OPTION FORM ZS / Z AC 7L 'So/ _
Tax Map & Lot No.
9-3 - s
Date
C�tiru�� zr e-YP JS10A)
Project Name
I realize that I must make a decision on payment of the Traffic Impact Fee
(TIF) at this time. Therefore, I request the following (choose whichever
option or options are applicable) :
Cash or Check
aCredit Voucher
Bancroft or Installment Payments
and/or.
The Ordinance allows for deferral of payment o: the TIF until
issuance of the occupancy permit if the TIF is greater than $5, 000 .00
If the TIF meets this requirement, I also request this option. I
understand the TIF must be paid prior to issuance of an occupancy
permit . I also understand that the TIF will be recalculated based on
the prevailing rates at time of payment . Please be advised that TIF
rates may increase up to six percent each July 1st . This rate
increase is not subject to appeal .
OWNER-APPLICANTWNER/ P_PL ICAN
CC: Building Permit File
Payment Option Notebook 1ogan\vio1a\tif02
CITY OF TIGARD
OREGON
August 29, 1991 \ j
J. Allan Pate.rFon
Century 21 Realty
12700 SW Pacific Highway
Tigard, OR 97223
RE: Traffic Impact Fee (TIF) for 12700 SW Pacific Highway
Dear .Mr. Paterson:
Attached to this letter you will, find a worksheet showing the
calculation used to determine the amount of the TIF due on the
conversion of the garage at the above address into additional
office space.
The total TIF due at the time you pick up your building permit for
this project is $1348 .00. If you wish, you may apply for credit
with the City and pay this amount in installments . If you wish to
use the installment payment option, please contact me as soon as
possible to make arrangements .
You will notice that I have selected the "general office" category
to use in calculating the TIF. The decision to choose general
office as the appropriate land use category is a discretionary
decision and is appealable to the Washington County Hearings
Officer. A •vritten sppeal. must be filed with the City Recorder
within 14 days of the date of this letter and must otherwise be in
accordance with Sections 18. 32 . 290(A) and 18 . 32 . 370 of the City of
Tigard Community Development Code. Appeal fee schedules and forms
are available at Tigard Cit-.y Hall, 13125 SW Hall Blvd. , Tigard,
Oregon.
Please note that this notification addresses only the Traffic
Impact Fee and do is not apply to any other fees associated with
obtaining a building permit.
If you have any questions or if I can be of further service please
contact me at 639-4171 ext. 390. Thank you.
SincerQly,
V;(�COnu�►•
Permits Facilitator
13125 SW Hall Blvd„P.O.Box 23397,Tigard,Oregon 97223 (503)639.4171— ------
DATE- RLANS CHECK NO.:
_ r- fig - � l -yac
PROJECT TITLE:
COUNTYWIDE —2- 1 COA1yi" smel(L�_
TRAFFIC IMPACT FEE APPLICANT:
WORKSHEET �• Ac.GA�c/ PAT�i.1 SDS _ __
MAILING ADDRESS:
(FOR NON-SINGLF.FAMILY USES) DO
CITY/ZIP/PHONE:
FATE PER -T&-A�1) 17,7,7 -4 !s_39� 2/d S
L,gNO E CATEGORY TRIP TAX MAP NO.: ZS f QAC TL. 1`j0/
R--SIDENTIAL _ $138.00
Q SllNESS AND COMMERCIAL 35.00 SITUS NO.ADDRESS:
ND LRtAL
Lj INSTITUTIONAL $57.00
PAYMENT METHOD:
CMH CHEQK
CREDIT INSTITUTIONAL ONLY:
BANCROFT PROMISSORY NOT D. LAND USE CATEGORY' 1011SCnIPTION OF USE EEKDA.l AVG TRIP RAT WEEKEND A TRIP RAIDEFER TO OCCUPANCY I GL / 4 ( 7 41 �114
BASIS:
t
77XW
14 —
'71/,
CALCULATIONS:
X6. 3 / lc-ccl ` ave-t l fu-r- ter_ ct
L
X /(. 13c �
PROJECT TRIP FNFRATION
�'G'Ti}� AnIDCl•V 7 Dt�� - — ---� F�� / 3Ycf.. c"�G
ADDITIONAL NOTES: FOR ACCOUNTING PURPOSES ONLY.
M115S mak' ,v i
.`
Z38.Do
EPAPFD BY. -
CC' WASHINGTON COUNTY �` T
TIF NOTEBOOK
form of 10
Nol-V I
MY OF TICAPD RECEIPT OF V,AYII(---N'F RECE I r-C'T NO. a 9 1 2 16722;,
CHECK AMOUNT - 118. 66
HOME x PACWEST REAL.'ry SALFS f-11CH AMOUNT . 0. 00
PIAPRE'SS x CENTURY 21 PAYMENT DATE a 081 E7,-)1
12700 SW PACIFIC MY SUBDIVISION
TIGARD, OR 97,P23—
PURPOSE OF PAYMENT AMOUNT PAID PURPOSE OF PAYMENT AMOUN'T PAIP
BU'IL-DING PERM 56. 150 PLAN CHECR FE 36. 73
TUMATIN VAIA. 22. 60 ST. BUILD PER 2. 83
1-01-14L nM(,)IJN-" V."ATO 118. 66
CITE' OF TIGARD
STOP WORK ORDER
BUILDING DIVISION
13125 SW IIALL BLVD., ►IGARD, OR 97223
0,19-4 171
JOB ADDRESS: _ - PERMIT #:
OWNER:J r�� l CONTRACTOR:
#YOU ARE IN VIOLATION OF THE FOLLOWING:
AND HEREP( NOTIFIED THIS DAY OF r 13._ AT _ < M,
THAT NO MORE WORK SHALL BE DONE ON THESE PREMISE UNTIL THE ABOVE VI LATION HAS
BEEN CORRECTED AND VERIFIED BY THE CITY. CORRECTIONS SHALL BE MADE WITHIN
DAYS OF THE ABOVE DATE. FAILURE TO COMPLY WITH THIS NOTICE WILL RESULT IN THE
ISSUANCE OF A CIV INFRACTIONS SUMMONS
-DO NOT REMOVE THIS NOTICE-
----- -------
BUI ING INSPECTOR
SIGW PERMIT
PERMIT Y: SGN91-0112 DATE ISSUED. . . . : V8/15/91
EXPIRATION DATE: j0 //S/9/
PARCEL. . . . . . . . . : 2SI02AC:-01701
ZONE. . . . . . . . . . . . CBD
BUSINESS NAME. . : CENTURY 21 PACWEST REALTY
SIGN LOCATION. . : 12700 SW PACIFIC HWY
APPLICANT/AGENT: KRISTA MAERZ
BUSINESS TAX NO:
SIGN:
PERMANENT (X) FREESTANDING (X) FREEWAY ( )
TEMPORARY ( ) WALL ( ) EL;ZCTRONIC ( )
OTHER ( ) BILLBOARD ( ) BALLOON ( )
SIGN DIMENSIONS. . . . . . : 5' X 7'
TOTAL SIGN AREA. . . . ,. . : 35 sq.ft.
WALL AREA. . . . . . . . . . . . . sq.ft.
WALL FACE (DIRECTION) : NA
SIGN HEIGHT. . . . . . . . . . : 20 ft.
PROJECTION FROM WALL. : in.
ILLUMINATION. . . . . . . . . : INT
DESCRIPTION OF SIGN:
PERMANENT FREESTANDING SIGN. 5' X 7' = 35
MATERIALS. . . . . . . . . . . . : METAL/PLASTC
EXISTING SIGNS. . . . . . . : 0
ELECTRICAL PERMIT REQUIRED: YES
BUILDING PERMIT REQUIRED. . :
ADMINISTRATIVE EXCEPTIONS. : N/A
PERMIT FEE: $ 25.00
APPROVED BY:
DATE: 08/15/91
Permit No.
CI'T'Y OF TIGARD
SIGN PERbLIV APPLICATION
Ili: appl.^ant hereby applies for a permit for thr indicated or as shown in the
accompanying Mans and specifications.
SIC24 .LOCATION ADDRESS: � 12700 SW Pacific Hwy � ZONING. "06' re,
NAME OF BUSINESS: Century 2.1 Pac_wnst Rea1 ty
Krista Maerz y 21 Pacwe 639-2125
APPLICANT/AGENT: _ COMPANY: Century — �iONE: �--
The City of Tigard imposes an annual Business Tax which must be kept current on all
persons doing business in the City. Do you presently have a current business tax?
YES ( X) NO ( ) U.L. Label
PROPOSED SIGN: (Check as many as apply)
PERIQ4MTr ( X ) FREF-STANDING ( X) FREEWAY ( )
TEMPORARY ( ) WIC ( ) nzc, I'RDNIC ( )
O'INFRR ( ) BILIDOARD ( ) BAIJ-DON ( )
SIGN DIMENSIONS: 5' X 7 ' Sj gn f rp, EXPIRATION DATE:
'ICITAL SIGN AREA (Sq. Ft..) : 3�, S❑. Ft
WALL AREA (Sq. Ft.) : ^.
HLA Z, FACE:
ETUGHT (Ft) : I'9tal Post heigh};_is
PRATE=ON FROM WALL: _
I11ihIIN1YI'ION: YES ( X) NO ( ) TYPE: g}oresenype light from within sign face.
COPY: _L.Qnj ury 21 Pacwest Realty __($fie sample)
MAZTRIAIS: Me to 1 & P 1 a-,t c
MSTING SIGNS: _ We wi .I I use exi Gt i nc s i qn post , extnndi nq _j_t_by_-_2__fect
Jg_11e_i a�-and a F_t o r-I i m y t h e ,i 4n a- ;_13 S S}u]SetLt._it1_L h r-
- sample sketch_ — -- -
A 14IMSIIZATIW EXCE3TTION: N/A ( z_-'' AP1WVED ( ) FiOW
AREA ( ) HEIGHT ( )
cu AruNTS:
PLANNING DEPAR 111ENTAll sign permits must be acccupanied by a scale
Permit Fee: -.rawing and plot plan. If work authorized under
Recce No: -.)I a sign permit has not been c rpleted within ninety
droved — A days after the issuanoe of the permit, the permit
Date: B - �!' - _ shall becaome null and void.
F.LBCIR.ICAL PERMIT I CER`T`IFY THAT 1 AM THE RDOORDED GWNFR OF' THF.
PBQUIRED: YES (I/r NO ( ) PRDPE3M- OR AN AGFNi' ALMIORI ZU) BY THP OWNF.
BUIIDING P13NIT , -
R."JIRED: YES (`')' NO ( ) Applicant's Signature
1 27O.a SW Pari f jr, Hwy
c{)/BKMPFRKr Address Telephone
N.-\WY m lTlMl m
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APPROVED
L^YTY OF TIG�,//ARD
HY.VJvkr A['TQbr, '
Tits, �Mtna,r'
n:,<< ;?L
•
GITY
or- r)r PAYMENT RrCEir-r' NO.
CHECK AMOUNT 00,
CASH nMOUNT 0. 00
NAME PACWEST REALTY SALES, INC PAYMENT DATE
ADDRESS m CENTURY 21 Poc"WEST RE74"ALTY Sj.jBD I V 113 1 ON
12*700 9W PACIFIC HIGHWAY PS CHECK
TIB'ORD, OR 97823-
AMOUNT PAID
PURPOSE Or: pAYMENT AMOUNT PAID PURPOSE OF PAYMENT
WrAL 011C)UNT PAID 2n. 00
I
r
Address Z6 d SvWX ��C��i Permit No.�
Name of Occupant Permit charge
Connection fee 772 5 d
Paid by aYaaP'
Date co eoted�y��=_(P�_
Type of Building �✓ _ Inspection fee
Service Rate d Paid by xAkwolc Date_ _
Contractor �-C/ Assessment _Paid
Size of Gonne Aion
I
i
i
PERMIT TO CONNECT
Tigard Sanitary District
PERMIT N? 661 DATE
PERMIT IS GIVEN TO
OF 11 2C ,:1 �. �•v, �...�A. c �a.��.
TO CONNECT A :� ..�.r q !_t
TO THE SYSTEM OF TIGARD SANITARY DISTRICT
l
THIS PERMIT MUST BE POSTED ON THE DES RIBF.D PREMISES UNTIL CON-
NECTION IS MADE AND INSPECTION OF CONNECTION HAS BEEN COM-
PLETED. 3
PERMIT FEE PAID ;... .4..........................TIGARD SAIARY DISTRICT
By
CONNECTION INSPECTED AND APPROVED
Date �� Superintendent