Permit CITY T SEWER CONNECTION PERMIT
�� DEVELOPMENT SERVICES
PERMIT #: SWR2005 -00200
: .� I I 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 DATE ISSUED: 7/1/2005
PARCEL: 2S1 01 AD -02800
SITE ADDRESS: 12665 SW 69TH AVE 100 ZONING: MUE
SUBDIVISION: WEST PORTLAND HEIGHTS LOT: 031 JURISDICTION: TIG
Project Description: .2 EDU increase.
TENANT NAME:
CWS NO: FIXTURE UNITS:
CLASS OF WORK: ALT DWELLING UNITS: 0.2
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Owner: FEES
CEDAR ENTERPRISES Description Date Amount
12665 SW 69 AVENUE
TIGARD, OR 97223 [SWUSA] Sewer Connection Fee 7/1/2005 $520.00
Total $520.00
Phone: 503 636 - 6657
Contractor:
REQUIRED ITEMS AND REPORTS
Phone:
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 0 . :00- 32 -234
Issued b Permittee Signature: ��
s y
Call 503 - 639 -4175 by 7:00 a.m. for an inspection t at 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 # 5 0 ,Q2800�" " # ?
� ,,� ,;, e a�x:� Via... &..�: ��;,..x� �iSas �E ''4'�'xu"c�. §,np ri ;, �; `•
T a M i t z a m e Cat,�so a g i i N a I R � ` � N a g i This SW R#2000024i ' MA Ai. +4!;''',Y1.. ::4
Site Address l >:*651SW 9th Ave ;S ,41.00i'_ xy ,' r This PLM# 2gD5 0 2$9 F a , • " ,:v
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
Ba tise /Font 0 ISM <
4 k'hk '`
Bath - Tub /Shower 4'' 0 0xZ -1 0 0 0
- Jacuzzi/Whirlpool 4 4 ; " g 0 0x=. .* 0 0 0
Car Wash - Each Stall 6 R 0 O 0 `�'`%w 0 0 0
— Drive through 16 %, 0 Rea 0 y 0 0 0
Cuspidor/Water Aspirator 1 3 :".t.-
Dishwasher - x ` s 0 ;' 0 ; : ;; 4 :� 0 0 0
Commercial 4 ;;;�:.:,� ��� � •:
- Domestic 2 NOM 0 0 0 0 0
yu,4 , t F R F w yr : 0 'v+' 4 D"t"'iA3s1
Drinking Fountain 1 � , 0 ,� , �, s sy � 0 0 0
Eye Wash 1 agieei 0 r.k 4 0 . f.Aigi 0 0 0
Floor Drain /Sink - 2 inch 2 t ' ti ' . `s • '` a
- 3 inch 5 .1.. < 0 : .: 0 14g..1 0 0 0
- 4 inch 6 4. It 0 . : . :A—r-. , i . •
0 - Car Wash Drr 6 0 'Y ..,, 0 ilrtiMi 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 : ; 0 41,% ... 0 ' . ..15.; `'' • 0 0 0
- Commercial (to 5 HP) 32 0 ; : 0 `, `` '` 0 0 0
- Industrial (over 5 HP) 42 Val : 0 3 ' . `• 4 • ":i 0 4 .`, 0 0 0
Ice Machine /Refrigerator Drain 1 • ' • 4 0. ,.e .
Oil Sep (Gas Station) 6 ; ° ';""&. ' > 0 r d 0 , „ ` 0 0 0
Rec. Vehicle Dump station 16 § '4 gw 0 . • , '' ' 0 %WPM 0 0 0
.x "_ • a s •tij ;:. ss� +' ...,
Shower - Gang (per head) 1 ; , ,4 0 z :; _ •,, 0 ;.; • :. 0 0 0
- Stall 2 ' A • p` ' .r 0 a4 Kt> ; 0 t ' ' ' a 0 0 0
Sink - Bar /Lavatory 2 1' 0 t %; k' 0 f, -..: ` 0 0 0
- Bradley 5 :, . `.. 0 k t z -- <,
0 - Commercial 3 .y, 4t4 0 1; 0 3 1 3
- Service 3 °, `, 0 0 :'� 0 0 0
Swimming Pool Filter 1 't :a1 0 0 5 0 0 0
Washer - Clothes 6 0e1 0 M. 11B 0 0 0
Water Extractor 6 ' ' ' : : 0 ... . 0 0 0 0
Water Closet - Toilet 6 2154 0 x ti ..> x ;
Urinal 6 tan 0 ' n f , ate 0 _^ 0 0 0
l a' "
Previous EDU Count : ` �, z 0 0
Capped EDU Credit:, :fir 0
TOTALS 0 0 0 0 1 3 1 3
Current Fixture Value 3 divided by 16 = 0.2 Current EDU 1 EDU = $ 2,600
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 3 divided by 16 = 0.2 over (under) $ 520.00
Enter EDU Change Here 2s' 102;
Notes:
Name: ,' 1 . d A Date: f ' s
Building Division
Note: The property owner shall retain this record for sewer credit purposes. In the event of a credit, this
document stamped "ORIGINAL" shall serve as a credit voucher and must be submitted to the City of
Tigard Building Division to redeem credit towards future system development charges. 7/1/05