12450 SW SUMMER CREST DRIVE 1 450 SW SUMMED. CREST DRIVE
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!NSPECTION NOTICE
City of Tigard Building impartment
12420 S.W Main St.
Tigard,Oregon 97223
Phone: 639-4171
Type of lnspet r.ion - �^—. ---- --- —
Date Requested —�,�� C` 8z — Time_ —. AM
Addres _:G�.e��!.�� '��:;�z��ermit #-_---
Owner ,_ __ LotBuilder
The ._ ------------_---- --- --- -- - --
The following Building Code deficiencies are re tuired to be corrected:
/ 4
C.
i
Presented to -- , ____ - -- -__ - Approved
Inspector -- _ '" _ _ .- --- _- _ ❑ Disapproved
Date ..-
CALL FOR RIT'INSPECTICN
YES r NO
SEWER PERMIT
Unified Sewerage Agency CITY OF DATE kiey
of Washington County —
OWNER: -�'► — -- _— PHONE ._ �a.3q�LLJ _.
OWNER 'S ADDRESS: i �S��
TYPE OF INSTALLATION:
, SIDE SEWER ❑ LINE TAP AND SIDE SEWER LJ LINE TAP
TYP,_ OF OCCUPANCY:
❑ NEW ❑ EXISTING SINGLE FAMILY ❑ COMMERCIAL
EXIST. (r3RIOR TO 7- 1-70 ) ❑ MULT. RES. ❑ INDUSTRJAL
IN
FIXTURE UNITS.__ DWELLING UI4ITS_.0-14_____.
ADDRESS OF STRUCTURE : r Qv AP, - -- - --
Permit Conditions: The applicant agrea,s to comply with all rules and regulations of the Unified Sewerage Agency.
When calling for Inspec!lon, please refer to the Permit Number. The Application expires in one hundred twenty (120)
days. The amount paid will be forfeited should expiation occur.
The Agency does not guarantee the accuracy of the location of side sewer laterals. If the sewer is not located at
the measurement given, the installer shall prospect three feet In all direction!; from the distance and depth given.
If not so located, thn Installer shall purchase a 'Tap and Side Sewer' Permit at the ctirrent charge and the Agency
' will install a laterad at the location specified by the installer.
FEES:
3y" Do
PEkMIT FEE O� _
CONNECTION CHARGE 3�� '
LINE TAP INSTALLATION -- ISSUED BY
OTHER 1
TOTAL
APPLICANT - _ _-- �—�- UF,l-F
SEVER PER�11T
ADDRESS OF STRUCTURE 'S a�� �_ �' 1 �_4
TAX MAP _1s �_•� G� TAX LOT _�u�062 _ SYSTEM
LOT B L O(:K "! __, O F i2C14yI_�__
APPROVED BY GATE n ISSUp,ED BY DATE ed
n. U. ' Se- REroARKSyr/ /JIhOp
E .11aMt,� � �i1� ? �1'G�C1Maf `J'`M�EGIWCe. _
a
C:aAt@ l� / J i' 4r„aF AMOUNT 5
_-..-s _...,. . __._ •rye j � _,.�._,,.,I� .._.... �
DOLLARS
NAME, GASH
ADDRESS
1... .i , { .. . 4. SOFmo
FOR
__ ACOT. # PERMITS IURCNARGE AMOUNT
SEWER BILLINGS 40.364
BUSINESS LICENSE 05-331
PLUMBING PERMIT 05.332 S
`
MECHANICAL PERMIT 05..332
BUILDING PERMIT 05.333
SEWER CONNECTION 40 363 -�
SEWER INSPECTION 40.365
SYSTEM DEV CHARGE 25-366
PARK f BEV CHARGE *1 30-361
I
PARK DEV CHARGE 02 30-368
ZONING ADJUSTMENTS r) 362
RK110 1) BY
s
PERMIT NUMBERS ASSIGNED: r
Number AMounl Number Armounl Nut"b!► Amounf
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