Permit 7 n CITY OF TIGA
SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT PERMIT #: SWR2007 - 00289
-. 13125 SW Hall Blvd., Tigard, OR 97223 5036394171 DATE ISSUED: 11/28/2007
T I GA R� a v . .
' PARCEL: 1 S 135AB -01002
SITE ADDRESS: 10220 SW GREENBURG RD 571 ZONING: R - 12
SUBDIVISION: LINCOLN CENTER/THREE LINCOLN LOT: 009 JURISDICTION: TIG
PROJECT: TRELLEBORG
Project Description: .3 EDU Increase
TENANT NAME: TRELLEBORG
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 0.3
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner:
SHORENSTEIN REALTY SERVICES FEES
ONE SW COLUMBIA ST #300 Description Date Amount
PORTLAND, OR 97258
[SWUSA] Sewer Connection Fee 11/28/2007 $840.00
Phone: 503 -412 -4800
Total $840.00
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 w 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: 1.. - 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.
` • ll Accumulative Sewer Tally Parcel # 1 S135AB -01002
Tenant Name: 'I•rellcborg This SWR# SWR2007 - 00519
Site Address: 10220 SW Grecnburg Rd., Ste. 571 This PLM# PLM2007 - 00289
fixture Value Previous Previous Credits Capped Fixture Fixturc New Ncw
# 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 0 0 0
- Domestic 2 0 0 0 0 0
Drinking Fountain 1 0 0 0 0 0
L Wash 1 0 0 0 0 0
. Floor Drain /Sink - 2 inch 2 0 0 1 2 1 2
- 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 -IP) 32 0 0 0 0 0
- Industrial (over 5 1 -IP) 42 0 0 0 0 0
Ice Machine /Refrigerator Dram 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 /1_avatory 2 0 0 1 2 1 2
- Bradley 5 0 0 0 0 0
- Commercial 3 0 0 0 0 0
- Service 3 0 0 0 0 0
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
(tapped [DU Credit 0
•1'O'1'AI,S 0 0 0 0 2 4 2 4
Current Fixture Value 4 divided by 16 = 0.3 Current EDU 1 EDU = S 2,800
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 4 divided by 16 = 0.3 over (under) S 840.00
Enter EDU Change Here 0.3
Notes:
Authorized Name /Signature: Dianna 1.,. Howse CX Date: 11/20/2007
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\ Forms \Sewcr•I allyShect.xls 02 /02/07