Permit 71
a CITY OF TIGARD SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT PERMIT #: SWR2008 - 00148
TiGARD, 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 10/28/2008
PARCEL: 1 S 135BC -00201
SITE ADDRESS: 10765 SW GREENBURG RD ZONING: C -G
SUBDIVISION: LOT: JURISDICTION: TIG
PROJECT: 7 -11
Project Description: .2 EDU increase.
TENANT NAME: 7 -11
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 0.2
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: LTPSWR IMPERV SURFACE:
Owner: FEES
BELANICH, ROGER M
BY SOUTHLAND CORP Description Date Amount
PO BOX 711
DALLAS, TX 75221 [SWUSA] Sewer Connection Fee 10/28/200E $620.00
Phone: Total $620.00
Contractor:
Contact #: REQUIRED ITEMS AND REPORTS
Reg #:
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" Permit and the Agency will install a lateral. ATTENTION:
Oregon law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling 503.246.6699
or 1.800.332.2344.
,
Issued by - ce —1.1....0—'- . — P ermittee Signature: /
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.
6CT -28 -2008 10:38 AM P. 2
, . Ph mbinn Permit Application I 56-(x2,10 0 8
Building Fixtures RECEIVED .." :,� , t y,r , 1.n, (►1:1_1 tit () =-'' a v c `µ
NW City of Tigard Received fO d i j Permit No., /2 L t h TC r t' 5
)
; ei 13123 SW Hall Blvd„ Tigard, OR 9722(' j 2 g 2.008 Flan Review �`�
., r • " Phone: 503.639.4171 Fax: 503.598.1 0� p Other Permit No.. ,. • i a "°' /
} ft -. Inspection Line: 503.639.4175 - - /
t Internet. erww.tigard-or.gov CrrY OF TI GAR D N Not fle M eth o d: S See
lemental Information
TYPE OF W∎ ;, , ,ILDI NG D I V1810 •
_ FEET SCHEDULE ..
❑ New construction ❑ Demolition
For special lnJbrnwtlon use checkl[rt
Description - Qty. 1 Ea. 1 Total
RAddition /attetatlon/replacement ❑ Other: New 1- 2- family dwellings (includes 100 ft. for each utility connection)
CATEGORY OF CONSTRUCTION SFR (1) bath 249.20
❑ 1- and 2- family dwelling ACommercial/industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- family SFR (3) bath 399.00
Each additional bath/kitchen 45,00
0 M
❑ aster builder ❑Other:
._t builder Fire sprinkler ( sq. ft.) Page 2
JOB. SITE INFORMATION AND LOCATION Site utilities
Job site address: lb to 5 ---- .5 t r4 J ,ye �b.,�,c,/ ( 121 Catch basin or area drain 16.60 MI
City/State/ZIP: •-r" r Q t 2 I Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.: 1 Project name: 7— / I Footing drain (no. linear ft.: Page 2 III
Manufactured home utilities 110.00
Cross street/directions to job site: CP Manholes 16.60
G' Rain drain connector 16.60
- .. l / . l .. . I Sanitary sewer (no. linear ft.: Page 2
►. I i �t g, Storm sewer (no, linear 11.: _J �
.� Mil Subdivision: Lot n Water service (no. linear ft.: Page 2
Tax map /parcel no.: Fixture or item
Absorption valve r 16.60
DESCRI OF WORK • Backtlow preventer Page 2
/ v c 5 : -,k_ i 4' v, r, Backwator valve 16.60
Clothes washer 16,60
Dishwasher 16.60
— ❑ PROPERTY OWNER . 0 TENANT Drinking fountain 16.60
EJectors/sump 16.60
Name: - '
Fvnunainn.tcnL — —.. , en --
Address:
city/state/z1P: Co ments regarding fixture work:
Phone: (. ) Fax: ( ) ' . g - r ... - 4/ 0 G✓' tv;-rL
1FTLICANC 0 CONTACT PERSON sp4,(T' 1 is 4,141. c: ,ra. - pyb -A - ..,
Business name: @. * '� R ^ C� eActk - ( 4,4 -ce J "1/'e. c- T
)� et 4 dP
, a
Contact name: 5 0 y � ( UI -r.
Address: (" 0 J u t r - 1 .
City / State/ZIP: F y r , 0,, 1 7 0 ?, Koor oralntcomrnentw7 •-.. ea _,,..v :,, ,,,
Phone: ( SD3) 7 . : {� '4 te:: (S y9i — � "7i Sinklbasinllavatory 16.60 1 , & G
Tub /shower /shower pan 16.60
E -mail: - Urinal 16.60
• CONTRACTOR Water closet 16.60
Business name: (ll. r . d Ill v r ,. i b f , Water heater 16.60 ' -
Address: Po 1 1 Other:
City/ State/ZIP: ,' j v I e, , a v - - 7 /9 ;7, c( Subtotal 1(�, �1
Minimum permit fee: $$72.30
Phone: (!,Z3) ,.5-7, , g i it Fax: (60 l ci _ v 6 . 7 1 Residential backflow minimum permit fee: $36.25 .)
CCB Lic -: ) OS 1 f PPlumb�ing Lic. no.: 1J 6 5 � P lan review (25% o f permit , (
C �� 2t State surcharge (1290 of permit fee) "� C7 I
Authorized signature: v'\
TOTAL PERMIT FEE , FJ , Q
Print name: R, D A ( 4e Date: 10 . _ 2 7._ 0 This permit application expires if a permit Is not obtained within
180 days after It has been accepted as complete.
"Fee methodology set by Tri- County Building Industry Service Board.
1:1Buitdlrtg\Permit PLMF- AermltApp. 12mro6 44O-4etat17o/02/COM/WaB)
. Accumulative Sewer Tally Parcel # 1S135BC -00201
Tenant Name:" 7 -11 This SWR# SWR2008 - 00148
Site Address: 10765 SW GREENBURG RD This PLM# PLM2008 - 00415
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
- 4 inch 6 0 0 0 0 0
- Car Wash Drn 6 0 0 0 0 0
Garbage Disposal
- Domestic (to 3/4 I -IP) 16 0 0 0 0 0
- Commercial (to 5 1 - 1P) 32 0 0 0 0 0
- Industrial (over 5 1-IP) 42 0 0 0 0 0
lcc 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 - 13ar /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 IKDU Credit 0
'10"I'AI S 0 0 0 0 1 3 _ 1 3
Current Fixture Value 3 divided by 16 = 0.2 Current EDU 1 EDU = S 3,100
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 3 divided by 16 = 0.2 over (under) S 620.00
Enter EDU Change Here 0.2
Notes:
Authorized Name /Signature: BRANDEN TAGGART Date: 10/28/2008
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.
I :\ Building \Sewer Tally \Sewer'1'allvSheet- 3100.xls 06/19/08