Permit 1 CITY OF T IG A RD
SEWER CONNECTION PERMIT
COMMUNITY DEVELOPMENT Permit #: SWR2010 -00085
,� Date Issued: 06/29/2010
TiGARI) 13125 SW Hall. Blvd., Tigard OR 97223 503.639.4171
Parcel: 2S102CC00500
Jurisdiction: Tigard
Site address: 13500 SW PACIFIC HWY 92
Subdivision: Lot: 0
Project: Fantastic Sam's
Project Description: .4 EDU increase
FEES
Owner:
13500 PACIFIC CORP Description Date Amount
BY CAPOZZOLI ADVISORY FOR, PENSIONS Sewer Connection Fee 06/29/2010 $1,440.00
INC, 21500 HAGGERTY ROAD,.SUITE,100
PHONE:
Contractor:
PHONE:
FAX:
Type of Use: COM
Class'of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .4
Total $1,440.00
Required Items and Reports (Conditions)
This permit is issued subject to thelregulations 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 t - egon
Utility Notification Center. Those rules are set forth in OAR 952- 001 -0010 through OAR 952 - 001 -0100. You may obtain a • • the - -
or direct questions to OUNC by calling 503. ...9' or .:'
Issued By • ' / _ PermitteeSignature:
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 # = ;2102 - „ � " "
Teri. Name''FANTASTICuSAMS`' j? $, it a r ? ` - This SWR# , *S7M2010 e' ' ''" ` ``
SiteAddress r13500W PACIFIC HWY SUITE,92„ _.,, ', `,.. This PLM# .= PLM201001955 „ ,:
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 ',;, . at h, : '; 0 0 d 0 0 0
Bath - Tub /Shower 4 ',AM 0 y ,`fLI . 0 Igigel 0 0 0
- Jacuzzi /Whirlpool 4 lli 0 I , _ t , . 0 4 .= 0 0 0
Car'Wash,- Each Stall 6 < 4R o 0:0a:; 0 taw o o 0
- Drive through 16 Z , . & •1 0 ,°'..l 0 <._.tiZI . ' 0 0 0
Cuspidor /Water Aspirator 1 . z i u ,.: 0, ,,, 0 F w - " t 0 0 0
Dishwasher - Commercial 4 � s `. ' 0 411.1k4 0 a . ,, 0 0 0
- Domestic 2 „�; ,` 0 „ m 0 yo . 0 0 0
XiA ".. �xt f a s ^d"G '
Drinking Fountain 1 „ �rre� 0 a li : 0" , .: 0 0 0
E Wash 1 c a ',.f, 0 -" `F'' "' 0 , s sJ 0 0 0
Floor Drain /Sink - 2 inch 2 "' A 0 NOM 0 '' 0 0 0
0 K, a ° 0 a ' '„,t
- 3 inch 5 �10 1 ,�� �.j� � .a .. ���. 0 0 0
-4inch 6 F '034441 0 ; a , , .' 0 , ....r s ;• 0 0 0
- Car Wash Drn 6 it 2r , -. 0 fi , - 0 "' ,,, w `? ,,, "' 0 0 0
Garbage Disposal
Domestic (to 3/4 HP) 16 0 1021 ry $ 0 x<s, ;r « „,: 0 0 0
- Commercial (to 5 HP) 32 taiga 0 ; a i,,_;: 0 ,,,,, m ig 0 0 0
@' ft o ve n x., .,
- Industrial (over 5 HP) 42 �,a„ 0 ,� '. y _ 0 8il ,,, 0 0 0
Ice Machine /Refrigerator Dram 1 Nitta tt 0. ,_ , ,, 0 'r ", 0 0 0
Oil Sep (Gas Station) 6 4 i 0 " - 0 ; 0 0 0
Rec, Vehicle Dump station ,16 p , IMI 0 i` s a_0 0 l � i. 0 0 0
Shower -Gang (per head) 1 t 4 0 ,? 0 .,° 0 0 0
- Stall . 2 ,„ F, 0 z 0 t, 0 0 0
Sink - Bar /Lavatory 2 ` i 0 qi •0 L . °1 0 0 0 •
- Bradley 5 x 41 y 0 .. " ti 0 , +max `e _; r°ii 0 0 0
- Commercial 3 r , , ;„ = „/ 0 ,,, ,. 0 gtniail 0 0 0
•Service: 3 Xx.. t $ 0 =" ,.. < .�`1 0 ,max >g eF" 0 0 0
y ." �r .
Swimming, Pool Filter 1 ' ��, ;. i ^ Ku „;. `; ' 0 - - 0 „� � , ` 0 0 0
Washer - Clothes 6 AMP, 0 ra l 7'. , ; _? 0 `1R., >_ "€ 6 1 6
Water Extractor • 6 Mira 0 ae,., £? 0 .w. 0 0 0
� „_ r�, .ry dd'
Water C g a rx loset - Toilet 6 i; 0 0 i ; ,,, �, �, 0 0 0
Urinal 6 114211 0 .0,t2,7Iiii 0 mom 0 0 0
"ar
Previous EDU Count 0 0
Capped EDU Credit t fi a i 0
TOTALS 0 _ 0 0 _ 0 1 _ 6 1 6
Current Fixture Value 6 divided by 16 = 0.4 Curreht EDU 1 EDU = $ 3,600
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU"
Change 6 divided by 16 = 0.4 over (under) $ 1,440.00
Enter EDU Change Here, ,044'
Notes: NONE
•
Authorized Name/Signature: ,Debbie Adamslp r Z:, u,. r,1s Date ;;� 6/,15/2016 „" ,
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- 3600.xls 06/25/08