Permit (31) CITY OF TIGARD SEWER CONNECTION PERMIT
114 sla COMMUNITY DEVELOPMENT Permit#: SWR2016 00368
Date Issued: 11/10/2016
TIGARD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S106DB09600
Jurisdiction: Tigard
Site address: 17380 SW AMELIA ST
Project: River Terrace Northwest,Lot 96 Subdivision: RIVER TERRACE NORTHWEST Lot: 96
Project Description: Sewer connection for new SF
Contractor: Owner: ADLV LAND HOLDINGS LLC
BY FORSUM, MICHAEL
7600 E DOUBLETREE RANCH RD STE 1
SCOTTSDALE,AZ 85258
PHONE: PHONE:
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 11/10/2016 $5,300.00
Sewer Inspection-Residential 11/10/2016 $35.00
Type of Use: SF
Class of Work: NEW
Install Type: Line Tap and Building Sewer
Fixture Units:
Number of Dwelling Units: 1
Total $5,335.00
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 or 1.800.332.2344.
Issued By: C6)7f2): z Permittee Signature: "7,,f�fel-j to"NI
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.