Permit (33) City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
Request for Permit Action # `" �
T I Gj A E;1-) 13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503-718-2439 •www.tlgard-or gov
>' t 3 2017
TO: CITY OF TIGARD
Building Division CM is ' OF £IG
ARD
13125 SW Hall Blvd.,Tigard, OR 97223 5UTIDING : ISI ,°
Phone: 503-718-2439 Fax: 503-598-1960 TigardBuildingPermits@tigard-or.gov
FROM: ❑ Owner [Applicant ❑ Contractor ❑ City Staff
Check(V)one
REFUND OR Name:
INVOICE TO: (Business or Individual) AD?__ vvey vA e
Mailing Address: OV A...AsAesk.c.K1,(xv\ 7\--,/...Q._.)
City/State/Zip: eA-Ae-.-- 6f. [j(Q
Phone No.: -t355— a D .g- —t---RA- --
PLEASE
"L`- --PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
a CANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit(.
Permit#: V-k-S7 " OC�5� �J%1�C; /fr'lJ l' " 7
Site Address or Parcel#: 1 5'5 S Vim' A • ' Weirdo` V 0
Project Name: ' lv" ' k (_%vb 35\(-A
� (S... . Lot#:
Subdivision Name: --V- . \ �"G / C �S\�C l
EXP ' ATION: 1 V .' . C A ! iivy---)
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Signature: ° LA rLA - L -S Date: �J`21-/ 17
Print Name: me,,,k t,�'4 we.6, IC--S
Refund Policy
1. The city's Community Development Director,Building Official or City Engineer may authorize the refund of:
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2. All refunds will be returned to the original payer in the form of a check via US postal service.
3. Please allow 3-4 weeks for processing refund requests.
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FOR OFFICE USE ONLY _
Route to Sys Admin: Date a 4,3 1? By E - Route to Records: Date `/ /Z /, B
Refund Processed: Date By Invoice Processed: Date By
Permit Canceled: Date (j f///7 By Parcel Tag Added: Date By
I:\Building\Forms\RegPermitAction_0923 4. oc
1,14„
CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT Permit#: SWR2016-00467
T I GAR. 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Date Issued: 04/24/2017
Parcel: 2S111 DA22700
Jurisdiction: Tigard
Site address: 15505 SW APPLEWOOD LN
Project: Heritage Crossing, Lot 46 Subdivision: HERITAGE CROSSING Lot: 46
Project Description: New SF
Contractor: Owner: DR HORTON INC.
4380 SW MACADAM AVE STE 100
PORTLAND, OR 97239
PHONE: PHONE: 503-222-4151
FAX:
FEES
Description Date Amount
Specifics: Sewer Connection Fee 04/20/2017 $5,300.00
Sewer Inspection-Residential 04/20/2017 $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 1.800.33 .2344. ^� j
Issued By: //���444����,�G�/) Permittee Signature: `5L,rA-4;
Call 503.639.41751by 7:00 a.m.for the next available inspection date. 111
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.