Permit (160) CITY OF TIGARD SEWER CONNECTION PERMIT
PeNrm-1 COMMUNITY DEVELOPMENT
it#: SWR2018-
Hall 13125 SW Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 12/10/2018
T I i; I?:i) 13125 Parcel: 2S1116D00700
Jurisdiction: Tigard
Site address: 14980 SW 96TH AVE
Project: Palmer Subdivision: DARMEL NO.2 Lot: 16
Project Description: Connect existing residence to public sewer.
Contractor: Owner: PALMER FAMILY TRUST
BY MILLER,JAN MARIE TR
22905 SW MOUNTAIN HOME RD
SHERWOOD, OR 97140
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 12/10/2018 $5,650.00
Sewer Inspection-Residential 12/10/2018 $35.00
Type of Use: SF Reimbursement District Fee 12/10/2018 $14,671.61
Class of Work: OTR
Install Type: Line Tap and Building Sewer
Fixture Units:
Number of Dwelling Units: 1
Total $20,356.61
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 503.23 987 or 1.800.332.2344.
Issued By: 400-7411
r - Permittee Signature:
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 c.mpletion of the project.
Approved plans are required on the job site at the time of each inspection.
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
NI Reimbursement District Payment Worksheet
TI G A R C) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
This worksheet must be completed by the Finance Department and provided
to the applicant to submit together with a completed plumbing permit
application and payment for sewer connection and reimbursement district fee,
if applicable, by expiration date shown below to the Building Division.
FINANCE DEPARTMENT TO COMPLETE:
Site Address: 14980 SW 96th Ave.,Tigard, OR
Reimbursement District #: 27 Parcel #:
Amount Due: $14,671.61 Amount Due Expires On: 3/8/2019
Applicant: • AA/ /7ss 2, Daytime Phone: .52 7t/ / _3 9.2.S.
Email Address:
❑ Sewer Loan Processed (journal entry to follow for payment of deferred sewer
connection fee and reimbursement district fee,if applicable)*
By: Maw Q Date: 12/3/18
Name
Printed: Mai Quach
BUILDING DIVISION TO COMPLETE:
*If a sewer loan is processed, wait forjournal entry before creating plumbing and sewer permits.
Reimbursement Amount Paid: $ /41, -7/• (v/ Receipt #:
SWR#: 020/J - 2Ø277 PLM #: ,v2,676F- '7
Enter parcel conditions in Accela (check all that apply):
Enter"paid" condition.
❑ Enter"deferral" condition,if applicable.
By: Date: % �te//e--'
Name
Printed: _�/4No✓21 / 717'4/.4'~
Attach this worksheet to issued sewer permit for records scanning.
I:\Building\Riembursement Districts\ReimDistPaymentWorksheet_NoDeferredAccounts_041918.docx