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Permit
CITY OF TIGARD SEWER CONNECTION PERMIT COMMUNITY DEVELOPMENT Permit#: SWR2015-00133 TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 10/20/2015 Parcel: 2S103BD00700 Jurisdiction: Tigard Site address: 12020 SW WALNUT ST Project: Holmes Subdivision: 2007-085 PARTITION PLAT Lot: B Project Description: Connect existing house to sewer service. Approximately 50'. Contractor: Owner: HOLMES, MELISSA M 12020 SW WALNUT ST TIGARD,OR 97223 PHONE: PHONE: FAX: FEES Description Date Amount Specifics: Sewer Connection Fee 10/20/2015 $5,100.00 Sewer Inspection-Residential 10/20/2015 $35.00 Type of Use: SF Class of Work: ALT Install Type: Line Tap and Building Sewer Fixture Units: Number of Dwelling Units: 1 Total $5,135.00 Required Items and Reports(Conditions) This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules or direct questions to OUNC by calling 503.232 I'87 or 1.800.332.2344. Issued By: • 1L� Permittee Signature: cam► Call 503.639.4175 by 7:00 a.m.for the next available inspection date. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT lig a Reimbursement District Payment Worksheet T I(;A k 1) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov This completed worksheet is to be submitted along with payment for sewer connection and plumbing permit application by expiration date below. ENGINEERING TO COMPLETE: Site Address: dad 0 S€ ) A/u-r 17 Reimbursement District #: i$ Parcel #: 2 s 10.319 D 00 2© 0 Amount Due: $ O Amount Due ExpireclOn: j'u,�e. 2. 7, 2.0 r, Applicant: Daytime Phone: ❑ 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 Agreement (signed prior to completion of worksheet) By: AI 8e,viv. Date: /6 .z f,s— BUILDING TO COMPLETE: Reimbursement Amount Paid: $ -�� Receipt #: /�- SWR #: / 3 3 PLM #: 2..Haots-Gb 35 Enter parcel conditions in Accela (check all that apply): ❑ Enter "pais" co. :i on. (\J7� ❑ Enter - erral" co ...tion, if applicable. By: Date: l°�"�' Y � �. Attach this worksheet to sewer permit for records scanning. I:\Building\Riembursement Districts\ReimDistPaymentWorksheet_021014.docx