Permit CITY OF TIGARD SEWER CONNECTION PERMIT
11
,e COMMUNITY DEVELOPMENT Permit #: SWR2009 00105
.TIGARD G A R O 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 10/07/2009
, Parcel: 2S 101 AD01300
Jurisdiction: Tigard
Site address: 12750 SW 68TH AVE
Subdivision: WEST PORTLAND HEIGHTS Lot: 33
Project: Clearchoice Dental
Project Description: .1 EDU increase.
FEES
Owner:
HAMPTON BUILDING, THE LLC Description Date Amount
75 -796 HIONA ST Sewer Connection Fee 10/07/2009 $360.00
HOLUAIOA, HI 96725
PHONE:
Contractor:
HARDER MECHANICAL
2148 NE MLK BLVD.
PORTLAND, OR 97208
PHONE: 503 - 281 -1112
FAX: 503 - 287 -5284
Type of Use: COM
Class of Work: ALT
Install Type: Building Sewer
Fixture Units:
Number of Dwelling Units: .1
Total $360.00
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 Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules
or direct questions to OUNC by calling 503.246.6699
jt /� .6699 or 1.800.332.2344.
Issued By: Van l.(J , v1 V� j �1�,` Permittee 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.
Accumulative Sewer Tally Parcel # 2s101ad01300
Tenant Name: Clearchoice Dental This SWR# 2009 -00105
Site Address: 12750 68th Ave. This PLM# 2009 -00279
I:ixturc 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
(;ar 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
F loor 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 I-1P) 32 0 0 0 0 0
- Industrial (over 5 1 -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 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
Capped EDU Credit 0
'TOTALS 0 0 0 0 1 2 1 2
Current Fixture Value 2 divided by 16 = 0.1 Current EDU 1 EDU = S 3,600
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 2 divided by 16 = 0.1 over (under) S 360.00
Enter EDU Change Here 0.1
Notes:
Authorized Name /Signature: Loraine Sellers Date: 10/7/2009
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 I'allyShect- 3600.xls 06/25/08