14370 SW HALL BLVD-2 !a
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CITYOFT167ARDSEWER CONNECTION
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COMMUMTY DEVELOPMENT DEPARTMENT ORmooN PERMIT #. . . . . . . : SWR92-0293 �
13126 SW Hdl Blvd. P.O.Boot 23397,TlgeM,Oregon 97223(6W)6394176 `
C. .] -6F 1. e 1 <'
SITZ: ADDRESS. . . : 14370 SW HALL BLVD PARCEL: 2SI12BB-03900 •
SUBDIVISI0h1. . . . : WILSON ACI-tE:S ZONlhl(.i: R-12
BLOCK. . . . . . . . . . . LOT. . . . . . . . . . . . . ..4
TENANT NAME. . . . . : ;
USA NO. . . . . . . . . . . FIX`T'URE 0\11TS. .
CLASS OF' WORK. . . :ADD DWELLING UNI TS. . : 1
TYPE OF* USE. . . . . :SF NO. OF BU I LD I NGS: 1
INSJALL IYPE. . . . :BUSWR Ih1F'r RV SURFACE. . : : : f
Remarks : Conect Lxisting ST'D to sewer. Septic tank to be pumped and filled with
sand or _gravel. Inspection of filled tank required. w
Owner.: ----__.__________.__.______.---__..______------_____________.____ FEES
T"Ohl MILLER BUILDER, INC. type amount by date rer-pt
12:4 i 5. W. EDGEWATER PRMT $ L100. 00 JLH 09/22/92 2311373
INSP $ 35. 00 JLH 09/:2/92 231873
1 TIGARD OR 97223 5
' Rhone #: 62:0--0767
Contrac'tot-.
OWNER
Phone #: $ :135. 00 TOTTIL
Rey #. . : 00000
-- - -- - REQUIRED T hISPECT I ONS -- -- ---
This Applicant agrees to comply with all the rul?s and regulations Sewer Inspection
of the Unified Sewage Agency. Tile permit expires 188 days from Septic Tank Fill
the date issued. The total amount paid will be forfeited if the
permit expires. The Agency does not guarantee the accuracy of the
I 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 Incated, the installer shall purchase
a "Tap and Side Sewer" permit and the Agency will install a lateral.
Permittee F.)iynature :
Issued B y � .. ...
Call for inspection - 639--4175
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13125S%" a Blvd. PLNCK/RECT # _ r
CITY OF T 1 G�ARD PO Rox IJ397 ^ r1'
COMMUNITY 1)EVELOI'M ENT I)EI ARTMI?N'(
Tigard,Oregon 97273 PERMIT � _-�
(303)639.171 DATE ISSUED
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JOB AnORESS: —_ TAX MAP/LOT
SUB: LOT: LAND USE: _
VALUATION: _
OWNER SPECfAL NOTES
NAME: ! –� �- � !�iG- �"�?_ REISSUE OF:
ADDRESS: _ LAST REISSUE:
FLOOD PLAIN/
PHONE: r� 7�J _ SENSITIVE LAND:
CONTRACTOR APPROVALS REQUIRED
NAME: _ _ PLANNING:
ADDRESS: ENGINEERING:
FIRE DEPT:
PHONE: OTHER:
Fw CONTR. BOARD #: EXP DATE:
ITEMS REQUIRED
SUBCON I-RACTORS: PLUMB: LIST/SUBCONTRACTORS:
MECH: _— BUS TAX: �____---__---
ARCH ENGINEER CALCULATIONS:
NAME: TRUSS DETAILS: —.-
ADDRESS: —^ OTHER: I
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PHONE: ^--------—--- — —
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PROPOSED BLDG. USE: _ __ .c� •��=
COMMENTS: —._ -- /�,�,, vr,'� �'�,�c , � s �. A;-'t —f-2> .z_1
APPLICANT SIGNATURE
Received By: — —_ ——_ — Date Received: ---- —____--
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PERMIT # ACCT # DLSCRIPIION AMOUNT AMOUNT PD. B�L:- DUE
10-432 00 Building Permit Ices _ I
10-431 00 Plumbing Permit Fees _ _ —
10-431 01 Mechanical Permit Fees _ `f
10-230 01 State Building Tax (5%)
Building
Plumbing
Mechan i ca I
10-433 00 Plans Check Fee
Bu i'.d'nq _
Plumbing _
Mechanical
10-230 06 Fire
30-202 00 Sewer Connection --- ---__—
30-444 00 Sewer Inspection _ 3-
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j 25-448-02 Commercial TIF Fees ___ _-- ----- — --
25-448-04 Industrial TIF Fees _
25-448-06 Institutional TIF Fees -
25-448-03 Office TIF Fees _ _ ---
25-448-01 Residential Traffic Fees —
25-448-05 Mass Transit TIF Fees --
52-449 00 Parks System Dev Charge (PDC)
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31-450 00 Storm Drainaq% Syst Dev Chrg
(SSDC)
24-445-01 Water Quality (Fee in lieu of)
2.4-445-02 Water Quantity (FeP in lieu of)
TOTAL
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nm/3587P.WPF I
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CITY OF1'Tf.�ARiJ FtE C;`nli f Ctt �'t1YMENT RF'CEIF'7 IVCl. 192n- 3187
t+
CHECK AMOUNT a 3535. 00
NAME a MILLER, TOM GA ISH AMOUNT a 0. 00
r�DTtPE 3S a PAYMPNT DATES a 09/ ':'/9 ' y
SUBDIVISION o
PUC7P SRE OF PAYMi._1,F AMOUNT PAID f,I,J RPOSE OF PAYMENT AMOUNT PAI h
GEWFR USA ,210lb. 1710 SEWER INSPECT _~ � 35. 00
Nr'i't QUAL.I TY FACILITY FEE 900. 00 H2O OIJANT I T Y F AC;'.l...I"I'Y FEE 5,00. 1210
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0-01._.ONY CHEEK
S WE'F2 PFRMIT FOR 14:370 SW FALL
1'IJ7A1_ F1InrtUN7 PAID -- _ 5. 0
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