Permit (52) CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT Permit#: SWR2017-00211
RD13125 SW Hall Blvd.,Ti and OR 97223 503.718.2439 Date Issued: 06/22/2017
Gf '1 9 Parcel: 25111 BA01700
Jurisdiction: Tigard
Site address: 14325 SW 97TH AVE
Project: Mitchell Subdivision: TIGARDVILLE HEIGHTS Lot: 32
Project Description: 1 EDU. Sewer Reimbursement District#41 fee paid on 6/22/17
Contractor: Owner: MITCHELL, MICHAEL W&PATRICIA T
14325 SW 97TH AVE
TIGARD, OR 97223
PHONE: PHONE: 971-777-4043
FAX:
FEES
Description Date Amount
Specifics: Sewer Inspection-Residential 06/22/2017 $35.00
Reimbursement District Fee 06/22/2017 $27,105.87
Type of Use: SF Sewer Connection Fee 06/22/2017 $5,300.00
Class of Work: ALT
Install Type: Line Tap and Building Sewer
Fixture Units:
Number of Dwelling Units: 1
Total $32,440.87
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 direquestions
to OUNC by c- . 232.1987 or 1.800.332.2344.
Issued By: Permittee Signature: A �, �'
Call 503.639.4175 by 7:00 a.m.for the next available inspecti.- date.
This permit card shall be kept in a conspicuous place on the job site until completion of the pr.'ect.
Approved plans are required on the job site at the time of each inspection.
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
.711
Reimbursement District Payment Worksheet
i t G n It C) 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: /1132.5" .S cl 7
Reimbursement District #: 11/ Parcel #: 2S III t3A( 1 70 0
Amount Due: $2 7� ( OOt -7 Amount Due Expires On: i/ 7/ 1 ce
Applicant: Pa if i c c, '7i , {c kJ! Daytime Phone: y o 3-S K .d..6to 3
❑ Sewer Loan Processed (journal entry to follow for payment) �`3- �` `3
Deferred Accounts (if applicable):
Owner: Daytime Phone:
Legal Description:
Amount To Be Paid: $
Amount To Be Deferred: $
❑ Deferral Agreement (signed prior to completion of worksheet)
BY: 6nq Date: 6'4241 17
BUILDING TO COMPLETE:
Reimbursement Amount Paid: $ 027 LOS-. Receipt #: 913
SWR #: 6lvQ c2 / 7- 60,9_4 / PLM #: J Po-0,r, DOS-f
Enter parcel conditions in Accela (check all that apply):
dill Enter "paid" condition.
❑ Enter "deferral" condition, if applicable.
B : O,A2_4,c4-4_44 Date: (p aQ;/''
Attach this worksheet to sewer peimit for records scanning.
I:\Building\Riembursement Districts\ReimDistPaymentWorksheet 021014.docx