12235 SW TIPPITT PLACE SW TI PPLT`I' PLACE
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AST
0 Y MJF TIGARD Plumbing P-',rtt' it t
Building Department NO.
Resider`ial Jam-} Coria?rcial [] �
New Installatic^ ❑ Replvice :� Addition ❑ Alteration ❑ Date
` Licensed
plumber D fe)"J ,vr. ('c Owner
Address 3//_/ %C i✓Cy7/ ,0,VP 5'7i ell —.- Job Address.��} Pf,cy T- _
Phone X34 --- Apr' .,iii
CITY SLISINESS LICENSE REQUIRED FOR AI.L Cn!JTRACTORS AND SUB-CONTRACTORS i
I - ITEM NO. FEE_ TOTAL ^�lTEwI MC). FEE TOTAL )
Fixtures•Traps 7.50 viewer:First 101 tt. _ _ 30.00 4
_Dishwasher _ _ _ 7.50 � Fach Addit.1('0 h. _ 15.00 _
Garbage Disposal 7.50 5` _ _Ejector Pump _ _ 7.5_0
Water Heater — _ 7.50 Water:First 100 R. _ 20.00
t
I
BackflowPrever,er 7,50 � _ Ec.ch Addit.?00 it. _ 1!.00 __ h
30.00
�
1 � _Storm E.Rain Drain,First 100 R 30.
. 00 _ }'
Each Addit.200 It. - — 15.00 #
Mobile Home Space T_ 2S 00
Ether(Specify): _ Rain C ain•Srngle Fam.Dwelling 15.00
PERMIT FEE 5.5 Comments:
STATE %
Issued By: - �-
Receipt No, r_ Appllcant
TOTAL1 - - --- — -
CHARGE ARGE a.
__j
C VJECTION FEE :E 7
OWNER
PAID HY
,7
TYPE OF BUILDING DATE CONNECTED
SERVICE RATE INSPECTION FEE
PAID BY DATE
CONTRACTOR ASSE55PIENT PAID
SHE OF CONNECTION
1.-,5 - 7 7
I
t
fY '
City of Tigard
INSPECTION REQUEST
for
INSPECTION TIME: > PERMIT NO. :----.
DATE : _L'/ �' DATE ISSUED
OWNERS NAME :ADDRESS:
CONTR.1%TOR
TEST * Air ❑, Water E}; Visual (] , L4bc)ratory (]
RESULT: Approved U Disapproved C , Pending I]
SKETCH.
l �
IINSPECTCR DATE
F_rTE : Attach supplemental tett dot b*reto�
1j'NIHED SEVVLRAGE AGI. NO. 9597
WASIAINGTON ("'fOUNTY L-)A.-rF
Tigard
igard
Al"PLICATION FOR SEWER CONNECTION PERMIT
oeoj,Ee IfTeusser
OWNEFI;: ,-.--- ------ ---
Rt. 1 Box 1.61 G
OWNER'S ADDRLSS: -.— - I
STREET
CITY STATE
BUILDING SITE: LOT— BLOCK . ADDITION
TAX LOT NO. TYPE OF OCCUPANCY --residenc-e----
12235 SW Tippett Ave Bldg. #4992
ADDRESS
DWELLING UNITS FIXTURE UNITS
SURCHARGE IF APPLICABLE
575-00 25-00 600.00
PERMIT FEE - -...........--. INSPFCI-ION rEE -- - TO,rAL DEPOSITED
(NEW) (EXISTING) BUILDING SEWER SYSTEM
The Applicant agrees to comply with all rules and regulations of the Unified Sewerage Agency.
APPLICANT - ------
SEVVE14 FERMI V
THIS PERMIT AUTHORIZES CONNECTION TO THE SEWER SYS I-VM.
L I N I-7'EINSTALLER
4
RECEIVED BY 4 e-
e-e
(AGENCY OR ITS 6i-N-6
cOMMENTS: - Leron Heights ';150,,00
This Application and permit expires in ninety (90) days. The amount paid will be forfeited
should expiration occur.