Permit CITY TIGARD SEWER CONNECTION PERMIT
��� DEVELOPMENT SERVICES PERMIT #: 0/8/01 1 -00278
�I II 13125 SW Hall Blv T igard, OR 97223 (503) 639 -4171 DATE ISSUED: 10/8/01
SITE ADDRESS; 12040 SW ROSE VISTA DR PARCEL: 2S103CC -02000
SUBDIVISION: COLONIAL VIEW ZONING: R -4.5
BLOCK: LOT: 015 JURISDICTION: TIG
TENANT NAME:
USA NO: FIXTURE UNITS:
CLASS OF WORK: DWELLING UNITS:
TYPE OF USE: SF NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Remarks: Reimbursement District #20.
A plumbing permit is required.
Owner: FEES
HAZARD, JOHN GERALD +
DARLINE GROGAN CO-TRS Type By Date Amount Receipt
12040 SW ROSE VISTA DR PRMT CTR 10/8/01 $2,300.00 27200100000
TIGARD, OR 97223 INSP CTR 10/8/01 $35.00 27200100000
Phone: Total $2,335.00
Contractor:
Phone:
Reg #:
Required Inspections
This Applicant agrees to comply with all the rules and regulations of the Unified Sewage Agency. The permit expires 180
days from the date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee
the accuracy of the side sewer laterals. If the sewer is not located at the measurement given, the installer shall prospect
3 feet in all directions from the distance given. If not so located, the installer shall purchase a "Tap and Side Sewer" Perm
Y.■
Issued by- 41110,,t. et, _, , 1 Permittee Signature: : •�� %� fir.
Call (503) 639 -4175 by 7:00 P.M. for an inspection needed t Inext b siness da 4
CITY OF TIGARD BUILDING INSPECTION DIVISION
MST
24 -Hour Inspection Line: 639 -4175 Business Line: 639 -4171
BUP
Date Requested / —� AM 9 - PM BLD
Location '/O 1 ( ��� ,..�9 ,� e l� ao Suite MEC
Contact Person �drDil � Ph p l 3 9 Sa4( , SO
Contractor Ph ® .Zoo / - 001 tr
BUILDING Tenant/Owner ELC
Retaining Wall ELR
Footing Access:
Foundation FPS
Ftg Drain SGN
Crawl Drain Inspection Notes:
Slab p-7 - SIT
Post & Beam
Ext Sheath /Shear
Int Sheath /Shear
Framing
Insulation
Drywall Nailing
Firewall
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
Roof / r
Misc: •
Final
PASS PART FAIL
PLUMBING
Post & Beam
Under Slab
Top Out
Water Service
Rai /rains
PART FAIL
CHANICAL
Post & Beam
Rough In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough In
UG /Slab
Low Voltage
Fire Alarm
Final
PASS PART FAIL
SITE
Backfill /Grading
Sanitary Sewer
Storm Drain [ ] Reinspection fee of $ required before next inspection: Pay at City Hall, 13125 SW Hall Blvd
Catch Basin
Fire Supply Line [ ] Please call for reinspection RE: [ ] Unable to inspect - no access
ADA
Otheoach /Sidewalk Date JO ^ — � Inspector p / 1 Lsc-/ t/ 'P , Ext
Final
PASS PART FAIL DO NOT REMOVE this inspection record from the job site.
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invoice
SEPTIC SERVICE
Name SAW 6a' � Date U
Address OD L ID SI1� RO I lJ1 12YyPhone (.1 JU q 5g lib
Cit Al q Initial On Acct.
State l YY Zip Code 6 1/),
Price Amount
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I. A V I n,
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• Al r al
ate/AK& 7 A" €7
NOT RESPONSIBLE FOR DAMAGES PAST CURB LINE OR LANDSCAPING
• A service charge of 1.5% will be levied on all past due accounts. Total: -----
• Returned check fee is $20.00.
• In case suit, action or arbitration is instituted by either party for breach or to enforce any
provisions herein, the court shall award reasonable attorneys fees and actual costs to the
prevailing party at trial or arbitration, or upon any appeal taken therefrom.
Approval
By:
Customer Signature
rfhanl -Y ou P.O. BOX 1136 • Canby, OR 97013 DEQ# 37464
(503) 263 -2087 or (503) 632 -6138 CCB# 104320