Permit (6) - CITY OF TIGARD SEWER CONNECTION PERMIT
��� DEVELOPMENT SERVICES PERMIT #: SWR2002 -00282
c� 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 10/4/02
SITE ADDRESS; 13727 SW PACIFIC HY 100 PARCEL: 2S103DD -00400
W
SUBDIVISION: ZONING:
BLOCK: LOT: JURISDICTION:
TENANT NAME: DR. FEELGOOD'S
USA NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: 1.3 EDU increase. Previous EDU =6.3 for a total of 108.8 fixture values. Addition of 20 fixture
values for a new total of 120.8 fixture values =7.6 current EDUs.
Owner:
FEES
WILSON'S TIGARD RETAIL CENTER Description Date Amount
BY BOMCC ESCROW ADMINISTRATION
TX1 -2495 [SWUSA] Swr Connect 10/4/02 $2,990.00
DALLAS, TX 75201
Phone: Total $2,990.00
Contractor:
Phone:
Reg #:
Required Inspections
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180
days from the date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee
the accuracy of the 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 located, the installer shall purchase a "Tap and Side Sewer" Perm
Issued by: Permittee Signature: /�
Call (50 639 -4175 by 7:00 P.M. for an inspection needed the next business day
Accumulative Sewer Tally -e-0
Tenant Name Dr. Feelgood's This SWRII 2002 -00282
Site Address: 13727 SW Pacific Hwy. Ste. 100 This PLM# 2002 -00358
Fixture Value Previous Previous Credits Capped Fixture Fixture New New
# value capped off value added added total total
count off #s count # value #s values
Baptisery/Font 4 0 0 0 0 0
Bath - Tub /Shower 4 0 0 0 0 0
- Jacuzzi/Whirlpool 4 0 0 0 0 0
Car Wash - Each Stall 6 0 0 0 0 0
- Drive through 16 0 0 0 0 0
Cuspidor/Water Aspirator 1 0 0 0 0 0
Dishwasher - Commercial 4 0 0 1 4 1 . 4
- Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
Eye Wash 1 0 0 0 0 0
Floor Drain /Sink - 2 inch 2 0 0 3 6 3 6
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Drn 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 0 0 , 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 HP) 48 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 1 1 1 1
Oil Sep (Gas Station) 6 0 0 0 0 0
Rec. Vehicle Dump station 16 0 0 0 0 0
Shower - Gang (per head) 1 0 0 0 0 0
- Stall 2 0 0 0 0 0
Sink - Bar /Lavatory 2 0 0 0 0 0
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 2 6 2 6
- Service 3 0 0 1 3 1 3
Swimming Pool Filter 1 0 0 0 0 0
Washer - Clothes 6 0 0 0 0 0
Water Extractor 6 0 0 0 0 0
Water Closet - Toilet 6 0 0 0 0 0
Urinal 6 0 0 0 0 0
Previous EDU Count 6.3 100.8 100.8
Capped EDU Credit 0
TOTALS 0 100.8 0 0 _ 8 20 8 120.8
Current Fixture Value 120.8 divided by 16 = 7.6 Current EDU 1 EDU = $2,300.00
Previous Fixture Value 100.8 divided by 16 = 6.3 Previous EDU
Change 20 divided by 16 = 1.3 over (under) $ 2,990.00
Enter EDU Change Here 1.3
HISTORY
Notes: PLM# 2002 -00336 EDU# 6.3 SWR# 2002 -00253
)U count from previous workshe PLM# EDU# SWR#
PLM# EDU# SWR#
Name: .A `. , _ /,,.. . _ ,1 Date: /0 — 3 Z. .
Signature of person that calculated this tally sheet and date perfromed is required
CITY OF TIGARD inspecroi! Lie: (503) 639 -4175
BUILDING MST
INSPECTION DIVISION Business Line: (503) 639 -4171
BUP
Received Date Requeste / 2 �� AM PM BUP
Location / 3 7 .+'l Pete_ / 2//9- tit Suite /Pd MEC
Contact Person D 6- -N Ph ( ) 1 , 1 5 39 PLM
Contractor Ph ( ) , l '13 "/ SWR dZ —'8
BUILDING Tenant/Owner pYf ELC
Footing ELC
Foundation Access:
Ftg Drain - fit ELR
Crawl Drain
Slab Inspection Notes: SIT
Post & Beam
Shear Anchors
Ext Sheath/Shear
Ina Sheath/Shear / � 3 •j J p
Framing p_iy\, v
Insulation
Drywall Nailing �J
O0 `� S
Firewall �IJJ
Fire Sprinkler
Fire Alarm
Susp'd Ceiling
/
R0000 f g i / Ca/ ` ''
Other:
Final
PASS PART FAIL
IrusliRts fP
Post & Beam
Under Slab
Rough -In
Water Service �
Sanitary Sewer (�( U
Rain Drains
Catch Basin / Manhole
Storm Drain
Shower Pan
Other:
I
op PART FAIL
ANICAL
Post & Beam
Rough -In
Gas Line
Smoke Dampers
Final
PASS PART FAIL
ELECTRICAL
Service
Rough -In
UG/Slab
Low Voltage
Fire Alarm
Final fl Reinspection fee of $ required before next inspection. Pay at City Hall, 13125 SW Hall Blvd.
PASS PART FAIL
SITE [] Please call for reinspection RE: 111 Unable to inspect — no access
Fire Supply Line
ADA 41)/ Approach/Sidewalk Date/ Inspector Ext
Other:
Final DO NOT REMOVE this inspection record from the job site.
PASS PART FAIL