Permit (133) CITY OF TIGARD SEWER CONNECTION PERMIT
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COMMUNITY DEVELOPMENT Permit#: SWR2017-00251
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 08/02/2017
Parcel: 2S103BA00600
Jurisdiction: Tigard
Site address: 11765 SW WALNUT ST
Project: Drake Subdivision: None Lot: None
Project Description: Sewer connection for existing residence.
Contractor: Owner: DRAKE, GEORGE L&LINDA K LIVING
11765 SW WALNUT ST
TIGARD, OR 97223
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 08/02/2017 $5,500.00
Sewer Inspection-Residential 08/02/2017 $35.00
Type of Use: SF
Class of Work: OTR
Install Type: Line Tap and Building Sewer
Fixture Units:
Number of Dwelling Units: 1
Total $5,535.00
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 503.232.1987 r 1.800.332.2344.
Issued B Permittee Signature: ' !tizex,e.
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
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
111111 3
Reimbursement District Payment Worksheet
TI G A R[) 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: 11765 SW Walnut St Tigard, OR
Reimbursement District #: 18 Parcel #: 2S103BA00600
Amount Due: $0 Amount Due Expires On: (.0/2 7/20/5—
Applicant: -Pr, Plum P2p E - W Daytime Phone: 503
IJ Sewer Loan Processed (journal entry to follow for payment)
Deferred Accounts (if applicable):
Owner: Daytime Phone:
Legal Description:
Amount To Be Paid: $
Amount To Be Deferred: $
❑ Deferral Agr-em-nt (signed prior to completion of worksheet)
By: Date: 34// 7
BUILDING TO COMPLETE: ,Og,b S Cei✓`✓Cei7e ni cIA/er
Reimbursement Amount Paid: $ Receipt #: Y/c2//y
SWR #: ft 2.20/ 7 -QQoi5/ PLM #: //°Lt7 CJ/ 7- C}.3/ .
Enter parcel conditions in Accela (check all that apply):
Enter "paid" condition.
❑ Enter "deferral" condition, if applicable.
By: 4#,AIPS Date: c,2 A7
Attach this worksheet to sewer permit for records scanning.
I:\Building\Riembursement Districts\ReimDistPaymentWorksheet 021014.docx