Permit CITY OF TIGARD SEWER CONNECTION PERMIT
a °:a COMMUNITY DEVELOPMENT Permit #: SWR2010 -00022
Date Issued: 02/17/2010
."11:1G � D 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171
Parcel: 2S110DB01300
Jurisdiction: Tigard
Site address: 15298 SW ROYALTY PKWY
Subdivision: Lot: 0
Project: Legacy Clinic
Project Description: .2 EDU increase
FEES
Owner:
PARR - FRANKLIN LLC Description Date Amount
1300 SW 5TH #2815 Sewer Connection Fee 02/17/2010 $720.00
PORTLAND, OR 97201
PHONE:
Contractor:
PHONE:
FAX:
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units: .2
Number of Dwelling Units:
Total $720.00
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 No • on Center. ose rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
or di -ct questions to OUNC • . i g 13.246.6699 or 1.800.332.2344.
Issued By: , / ' a2._Also.4. Permittee Signa`t re: , /fi(I / ee-
/
Call 503.639.4175 by 7:00 a.m. for an inspection that business day.
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.
Accumulative Sewer Tally Parcel # 2S110DB01300
Tenant Name: Legacy Clinic This SWR# 2010 -00022 ' .
Site Address: 15298 SW Royalaty Pkwy This PL.M# 2010 -00050 '
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
Baptistry/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 0 0 0
- 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 0 0 0
- 3 inch 5 0 0 0 0 0
-4inch 6 0 0 0 0 0
- Car Wash Drn 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 1 -IP) 16 0 0 0 0 0
- Commercial (to 5 HP) 32 0 0 0 0 0
- Industrial (over 5 I -IP) 42 0 0 0 0 0
Ice Machine /Refrigerator Drain 1 0 0 0 0 0
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 0 0 0
- 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 0 0
Capped EDU Credit 0
TOTALS 0 0 0 0 1 3 1 3
Current Fixture Value 3 divided by 16 = 0.2 Current EDU 1 EDU = S 3,600
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 3 divided by 16 = 0.2 over (under) S 720.00
Enter EDU Change Here 0.2
Notes:
Authorized Name /Signature: Debbie Adamski Date: 2/17/2010
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher which must be
submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
1 : \Building \ Sewer Tally \Sewer 1'allyShect- 3600.xls 06 /25/08