Permit CITY OF TIGARD SEWER CONNECTION PERMIT
1 1 t: • - COMMUNITY DEVELOPMENT Permit #: SWR2012 -00053
TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/23/2012
Parcel: 2S102CD03005
Jurisdiction: Tigard
Site address: 9965 SW MCDONALD ST
Project: DelaCruz Subdivision: FREWING'S ORCHARD TRACTS Lot: 30
Project Description: Plumbing permit for sewer connection.
Contractor: Owner: DELACRUZ, ELDON
9965 SW MCDONALD ST
TIGARD, OR 97224
PHONE PHONE:
FAX:
FEES
Description Date Amount
Specifics: Deferred Reimbursement District Fee 03/23/2012 $19,464.00
Deferred Sewer Connection Fee 03/23/2012 $4,500.00
Type of Use: SF Deferred Sewer Inspection Fee 03/23/2012 $35.00
Class of Work: OTR
Install Type: Line Tap and Building Sewer
Fixture Units:
Number of Dwelling Units: 1
Total $23,999.00
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 50 32.1987 or 1.800.332.2344.
Issued By: PermIttee Signature: /7167-(19-
Cali 503.639.4175 by 7:00 a.m. for the next available inspection date.
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.
El III CITY OF TIGARD RECEIPT
. 1 3125 SW Hall Blvd., Tigard OR 97223
503.639.4171
TIGARD
Receipt Number: 186052 - 03/23/2012
CASE NO. FEE DESCRIPTION REVENUE ACCOUNT NUMBER PAID
SWR2012 -00053 Deferred Reimbursement District Fee 500- 0000 -23300 $19,464.00
SWR2012 -00053 Deferred Sewer Connection Fee 500 - 0000 -23300 $4,500.00
SWR2012 -00053 Deferred Sewer Inspection Fee 230- 0000 -23300 $35.00
Total: $23,999.00
PAYMENT METHOD CHECK # CC AUTH. CODE ACCT ID CASHIER ID RECEIPT DATE RECEIPT AMT
Journal Entry 369 -09 -2012 DHOWSE 03/23/2012 $23,999.00
Payor: City of Tigard Loan for DelaCruz
Total Payments: $23,999.00
Balance Due: $0.00
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Page.1 of 1
General Ledger
Journal Entry Proof List
User: amyl • Z
Printed: 3/23/2012. 12:05 PM
Batch: 10019.03.2012 T 1 G A R D
Account Number Account Description Debit Amount Credit Amount Line Description Project Management
Journal Entry: 369-09 -2012 Journal Entry Date: 03/23/2012
230 - 0000 -12103 Accts Receivable - Reimb. Dist 35.00 0.00 Sewer Connection Loan - DclaCruz
230- 0000.23300 Deferred Revenue 0.00 35.00 Sewer Connection Loan - DelaCruz
500- 0000 -12102 Accounts Receivable - CWS 4,500.00 0.00 Sewer Connection Loan - DelaCruz
500 -0000 -12103 Accts Receivable - Reimb. Dist 19,464.00 0.00 Sewer Connection Loan - DelaCruz
500- 0000 -23300 Deferred Revenue 0.00 23,964.00 Sewer Connection Loan - DelaCruz
Journal Entry Totals 23.999.00 23,999.00
Journal Entry Balance 0.00
Report Totals: 23,999.00 23,999.00
0.00
GL-Joii Entry Proof List (3/23/2012 - 12:05 PM) Page 1
City of Tigard
• 114
,
- L ,,-;_, Sewer Connection Fee Loan Apphcatton
-- - -- - — -, - - - — • ' -, - "---•-
• I (We), the imdersigned owner(s) of property described beim% request installment payments for the sewer
:reimbursement district fee and sewer connection fee. I (We) understand that the required plumbing permit and the
cost of installing the plumbing required to connect to the sewer are not included in the installments.
, . /
Name of ownerN: &" /do)) • De ie. ( e ,-, •
Site address: • .." - , rx. id sic-ee f 77, u i.,/ 0,- 432 .el 2 4
Tax rnap and tax lot #: 2.5 JO 2 C .1) 0 3 00-5
,
Mailing address (if diffelent thin site addtess):
Owner's signature: Zri/."(7.. D am; 3
Print name: Eldon defaCruz ph 503.705.7933
Owner's signature: Date:
Print name: Phone:
FOR STAFF USE ONLY:
Reimbursement district name/�o.: 2:_..42,4ti id A IA: ZA •
Legal description: iecoi-eie d cd 20c 4- - f04
_..,
Expiration date of three deferral period: CI c y 2 : ?I3 ?Amount deferech $ 0
Fees assessed for loan:
Reimbursement district fee: - 4li 44 Plai 2 . 5 ; g sop-No-int* •:$ /3 ,.*: - 4 1-
)
Sewer connection fee through June 30;:20i2. : 500-0000-23300 $ • 4 > C. C V
Inspection fee: • 230-0000-23300 •
Total fees for loanamOnnt: $ 2 3 , c.' , 3 :/
Application approved by: Date:
, .
City of Tigard' I 13125 SW hail Blvd , Tigard, OR 97223 I sarww.tigard-nr.gov
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