Report (30) ti
City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT
41 Reimbursement District Payment Worksheet
111111
i ,, ,, 13125 SW Hall Blvd. •Tigard, Oregon 97223 • 503.718.2439 • www.tigard-or.gov
This completed worksheet is to be submitted along with payment for sewer
connection and plumbing permit application by expiration date below.
ENGINEERING TO COMPLETE:
Site Address: '75/7 %$W C4f_OY £.
Reimbursement District #: /l'Q Parcel #: 2.S l Q 1 DC O 1800
Amount Due: $ r , '25. (4 Amount Due Expires On: A/0 y Z 3,20/8
Applicant: Ko,renrq Daytime Phone: 503 - (97 I - 7957
❑ Sewer Loan Processed (journal entry to follow for payment)
Deferred Accounts (if applicable):
Owner: Daytime Phone:
Legal Description:
Amount To Be Paid: $
Amount To Be Deferred: $
❑ Deferral Agreement (signed prior to completion of worksheet)
By: ,. .T�8 Date: /-/0 -20/8
BUILDING TO COMPLETE:
Reimbursement Amount Paid: $ 1 7l 7,Z5;6,6,, Receipt #: 1§'36.3
SWR#: 54)12,2 D/if-000 3`3 PLM #: PZ.-/Lt /i..ODO 4/3
Enter parcel conditions in Accela (check all that apply):
[4 Enter "paid" condition.
❑ Enter "deferral" condition,if applicable.
By: �w /4; #r" Date: l�l
Attach‘,.../.,,,ir-
'.'t3,/ ‘./
worksheet to sewer permit for records scanning.
I:'Building\Riembursement Districts ReimDistPaymentWorksheet 021014.docx