Permit IN CITY OF TIGARD SEWER CONNECTION PERMIT
ii : ° COMMUNITY DEVELOPMENT PERMIT #: SWR2006 - 00315
4)6 13125 13125 SW Hall Blvd., Tigard, OR 97223 503.639.4171 DATE ISSUED: 12/15/2006
PARCEL: 2S 113AB -00101
SITE ADDRESS: 16101 SW 72ND AVE BLDG A -120 ZONING: IP
SUBDIVISION: PACTRUST BUSINESS CENTER LOT: JURISDICTION: TIG
Project Description: .5 EDU increase.
TENANT NAME: QUALCOMM
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ADD DWELLING UNITS: 0.5
TYPE OF USE: CMS NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner: FEES
PACIFIC REALTY ASSOCIATES
15350 SW SEQUOIA PKWY #300 -WMI Description Date Amount
PORTLAND, OR 97224
[SWUSA] Sewer Connection Fee 12/15/200E $1,350.00
Phone: Total $1,350.00
Contractor:
REQUIRED ITEMS AND REPORTS
Contact #:
Reg #:
This Applicant agrees to comply with all the rules and regulations of the Clean Water Services. The permit expires 180 days from the
date issued. The total amount paid will be forfeited if the permit expires. The Agency does not guarantee the accuracy of the side sewer
laterals. If the sewer is not located at the measurement given, the installer shall prospect 3 feet in all directions from the distance given.
If not so located, the installer shall purchase a "Tap and Side Sewer" Permit and the Agency will install a lateral. ATTENTION: Oregon
law requires you to follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through
OAR 952 - 001 -0100. You may obtain copies of these rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344.
Issued by: Permittee Signature: ,S.12 'e_
Cali 503.639.4175 by 7:00 a.m. for an inspection that business day.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
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P lumbin Permit Application
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2006 .: a * . .71 F OR l�l g Ll � . . ,, „. : b� „'
` ' City of Tigard Received /
Date/By. /2 4 a0 may PermitNo.: 6i'/ j0 (ti GOj$��
V 13125 SW Hall Blvd, Tigard, OR 9723 � P Review _
'i.1_ a Phone: 503.639.4171 Fax 503.59 ° �� 1 x�� By Other Permit No. e i�, -"CO 3/5
rr Inspection Line: 503.639.4175 B�' , I g 9 t V ( r Ir. � ead /B J 4 1_ H Se e p
T��� G" C ND) 1 Y Y �+ age 2 for
.•1a. 14 Internet www.tigard- or.gov ' ed/Method:/ ' /,,u0 ' /G,1• Supplemental Information
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s v .,', lW . g. bi. t OF OR K Y.� ' ' . 'r . ' .s ; a .N or: i ' S. ,. FEE'' GHEDUY',, ik t Avr, 4x*, � , n' ,...4A',1:;,'4.::: ; ,�t,r..:k:
M�' �.^ iJ* 4� Nitt[..: Y�: �. �w. �d... f; �: i'. :L'_::1.r�,uJ._S:!xP.�'M...u. �'�... z�s �..�.. �. L.. �` s �; �• . �., g' ..4.'.. $kt •: a ..+ �..,, v�ti, r.'.. z^ �cruur !t�ii:Yr- 37,c c . .vs�*.11''
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❑ New construction ❑ Demolition , For special information use checklist
New 1 1 -
Description Q.? 1 Total
® Addition /alteration/replacement ❑ Other. - 2-family dwellings ('includes 100 YL for each utility connection)
f . ,1 5 ,d)7& a kTIEGOiii4 1 >COl!tS' liiit7�}t. ON ' ` c .' -` u'r 0 , 1 M` ..� r ` , , ,, l SFR (1) bath 249.20 4.
❑ 1- and 2- family dwelling ® Commercial/ industrial SFR (2) bath 350.00
❑ Accessory building ❑ Multi- fancily SFR (3) bath 399.00
El Master builder Each additional bath/kitchen 45.00
❑ Other
r ry �� , Fire sprinkler (�_ sq. ft.) Page 2
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E` t et A ; JOB SI:EiIAI : ::1'° AfiIOi,�'` "^•` i . s
�_..',,.,, ..,r.,. k....nr.� -.� :�x�:_ N.a:�,.,,,�:. U.�,. �. .�,a,,.;�,,or5�� tr,,,�?�,'t�f,_'r � ._� Site utilities
Job site address: 16101 SW 72 Ave Catch basin or area drain 16.60
City/State/Z1P: Tigard, OR 97224 Drywell, leach line, or trench drain 16.60
Suite/bldg. /apt. no.;,&8(rap I Project name: Qualcomm Footing drain (no. linear ft: ) Page 2
Manufactured home utilities 110.00
Cross street/directions to job site:
Manholes 16.60
Rain drain connector 16.60
Sanitary sewer (no. linear IL: ) Page 2
Storm sewer (no. linear ft: ) Page 2
Subdivision: I Lot no.: Water service (no. linear R: _) Page 2
Tax map /parcel no ,,;25 / / 03 09 6 00 / e / Fixture or item
�r Yfiajr a , � xa nrxa • s n, dr�� , .g.. - o ,- ,-.4' .a aa4 t . & Absorption valve 16.60
y "� ` pa '*?? , 5''• D - W ORI�y gi i? 4 � ea .et. # .'?!. In " i '
:�d�.. Ne..at..x°E��� . a. ,,.,n g ... muss -,t ., �.M1:? .,�:.- .l�Y >n , ,:1"• a..,...»..�`,':.« BackflOW preVanter Page 2
Plumbing for tenant improvement Backwater valve 16.60
Clothes washer 16.60
Dishwasher 16.60
r `!"/ r n K+ '. , �, y w, d T a•+ N•'Y�,'�, Iy� -k+ *„ �' �`� ✓' N-:' -++ Drinking fountain 16.60
x4` ig ®i 3t • ` Os Y x� ' . 04:1 = a �` �`;� ®�S`I riiir. I. Toy s i f l � '
ti u: - s cF. ;$3,..- .. saK.u, > ...M ,,,. _.n ..Y.. •r,,.,:s,,...,t.. -- k Y �,, 4 ..5 . E ` ! Ejectors/sump 16.60
Name: Expansion tank 16.60
Address: er ca 16.60
City/State/Z1P: ( IF- Floor drain/ i r or sink/hub A. i 1 16.60 16.60
Phone: ( ) Fax: ( )
err. ge disposal 16.60
+ ; rte�c,, ti uy e i ii tAP�I r 3 r r. .. w *'�. Tile i t m 11) r �!�SON4 .7. 1 Y rss Hose bib 16.60
ri . -g Ji� . k<... .......:a+,... aa.A !A +?'t ...,k} :l,"' r;a ✓ y ,,,zo..t"� .v: ICe maker 16.60
Business name: Interceptor /grease trap 16.60
Contact name: Medical gas (value: $ ) Page 2
Address: Primer 16.60
City/State/ZIP: Roof drain (commercial) 16.60
Phone ( ) I Fax • ( ) Sink/basi. avatory) 2 16.60 33.20
T • show- r shower pan 1 16.60 16.60
E -mail: Urinal 16.60
s(i• ''+,,1, tr : -,�a � �-,.�c M,- ,* -rt a�..rt ,neus a r�r ax +c ,w,'�c '�-� •�pt��e�;� s i '� t� �
! " �{ 1 ,x. 1k.&,1 i',4,2:''�.A *,,'CON GT(..12.« , 04 ;4 ;,'k � g A44 -a°. , ._ trt.. , Water closet 16.60
Business name: PMSI LLC Water heater 16.60
Address: 21195 NW Evergreen Pkwy Suite 204 Other.
City/State/ZTP: Hillsboro, OR 97124 Subtotal 66.40
Minimum permit fee: S72.50 72,50
Phone: (503) 466 - 2222 Fax: (503) 466 - 2211 Residential baekflow minimum permit fee: 836.25
CCB Lic.: Plumbing Lic. no.: 34 - 434PB Plan review (25% of permit fee)
/
Authorized signature / State surcharge (8% of permit fee) 5.80
�� _ # v
( TOTAL PERMIT Y�EE 78.30
Print name: Lanell • obinson I Date: 12/12/06 I This permit application expires if a permit is not obtained within
180 days alter it has been accepted as complete.
*Fee methndnlnvv net by Tri.Caunty Ruildinv Tndus,ry Service Rnard.
. ,Accumulative Sewer Tally Parcel # 2S113AB - 00101
Tenant Name: Qualcomm This SWR# 2006 -00315
Site Address: 16101 SW 72nd Ave A -120 This PLM# 2006 -00589
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 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 1 2 1 2
- 3 inch 5 0 0 0 0 0
- 4 inch 6 0 0 0 0 0
- Car Wash Drr 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) 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 1 2 1 2
Sink - Bar /Lavatory 2 0 0 2 4 2 4
- 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
Capped EDU Credit 0
TOTALS 0 0 0 0 4 8 4 8
Current Fixture Value 8 divided by 16 = 0.5 Current EDU 1 EDU = $ 2,700
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 8 divided by 16 = 0.5 over (under) $ 1,350.00
Enter EDU Change Here 0.5
Notes:
Authorized Name /Signature: Debbie Ada ki Date: 12/13/2006
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 \SewerTallySheet.xls 7/1/06