Permit _. .
A - CITY OF TIGARD SEWER CONNECTION PERMIT
i DEVELOPMENT SERVICES PERMIT #: SWR2004 -00312
-I I- 13125 SW Hall Blvd., Tigar OR 97223 (503) 639 -4171 DATE ISSUED: 10/27/2004
SITE ADDRESS; 16398 SW 72ND AVE B -08 PARCEL: 2S113AA -00200
SUBDIVISION: OREGON BUSINESS PARK I ZONING: I -L
BLOCK: LOT: 002 JURISDICTION: TIG
TENANT NAME:
USA NO: FIXTURE UNITS: 0
CLASS OF WORK: ALT DWELLING UNITS:
TYPE OF USE: COM NO. OF BUILDINGS:
INSTALL TYPE: BUSWR IMPERV SURFACE:
Remarks: .8 new edu.
Owner: FEES
PACIFIC REALTY ASSOCIATES Description Date Amount
15350 SW SEQUOIA PKWY #300 -WMI
PORTLAND, OR 97224 [SWUSA] Swr Connectic 10/27/2004 $2,000.00
[SWUSA] Swr Connectic 10/27/2004 $0.00
Phone: 503- 624 -6300
Total $2,000.00
Contractor:
ADDISON PLUMBING
17506 SE RIVER RD. .
MILWAUKIE, OR 97267
Phone: 503- 785 -1840
Reg #: LIC 151754
PLM 3 -449PB
Required Inspections
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 obtai of these rules or direct questions to OUNC by calling (503) 246 -6699.
Issued ��,p Perm ittee Signature: r /� % / i - AP - V '
Cali (503) 639 -4175 by 7:00 P.M. for an inspection needed th/ ext business day
Accumulative Sewer Tally 200��
Pa 2S113AA 11 k " n
Tenant Name: irface MountTech94 y ` jk ; This SWR #2004,003 12" , MXtg .., ` OS1,`
::.b . . ,r ;; This PLM# ° 0U4 004,85 z ; �,o $ k:_�> r•, �?'�
Site Address � 1iti398� SW 72nd'Ave # 6 =08 � " �:<� �xw , - �. � � � �`- ' �`s �` ' '
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 4 ; -z;7? 0 :'4':;Zj,VW1 0 0 0
Bath - Tub /Shower 4 1t ':;w M 0 ,<<.,,R :. 0 n `, z' >F 0 0 0
- Jacuzzi/Whirlpool 4 " ,r '' 0 ' ; -: 0 : ' , . - s � 0 0 0
Car Wash - Each Stall 6 .� O 0 ,e F, 0 0 0
- Drive through 16 E s, 0 0
Cuspidor/Water Aspirator 1 , ' 0 dam: ' : 0 : �, rvc° 0 0 0
Dishwasher - Commercial 4 4 ,,: 0 , ` ; 0 MIN , 0 0 0
- Domestic 2 e :, ; , 7 _ 0 0 f 0 0 0
Drinking Fountain 1 4 , 0 5, :6-. 0 '.�r #r eq. 0 0 0
Eye Wash 1 2 0 „? 0 ` ' � a ^ 0 0 0
• Floor Drain /Sink - 2 inch 2 `,
,'!s h, 0 , ' 'v. ; : 2 0 -1 -2
- 3 inch 5 r i4114. '' 0 itKet 0 4 r 0 0 0
- 4 inch 6 i el ;. % s.;" 0 ;`X 0 0 0 0
- Car Wash Drn 6 ' c,o~'z 0 F° 0 of f 0 0 0
Garbage Disposal
- Domestic (to 3/4 HP) 16 w 0 x , { ; 0 1 % '
- Commercial (to 5 HP) 32 ti:-4.'W 0 0 :` 0 0 0
��s� j .r.._a� "AKA ,fir:.
- Industrial (over 5 HP) 42 n' 5: 4, , 0 , ' j 0 ,� 0 0 0
w «` f r ., >� : -;
Ice Machine /Refrigerator Drain 1 "f ;:�'x 0 ��� 0 � '�,4 0 0 0
Oil Sep (Gas Station) 6 0 F_ 0 ?. 0 0 0
Rec. Vehicle Dump station 16 ." " 0 f Ip <z' 0 1k703 0 0 0
Shower - Gang (per head) 1 0 '; 0 s 0 0 0
- Stall 2 r , S Y 0 , k 0 ';.'r 'k %' 0 0 0
Sink - Bar /Lavatory 2 ;�:.' ;,' 4 : , 0 , -: > < 0 :*:'4,S, 2 1 2
- Bradley 5 l `; 0 ''', 0 t 0 0 0
- Commercial 3 „ 0 it,, -1 0 t a- �'. 0 0 0
3 �3,. 3 is
- Service 3 1 <i 7 0 0 ; y -: 0 0 0
Swimming Pool Filter 1 > ` 04 0 7 0 0 0
Washer - Clothes 6 44* 0 164.b 0 yA 0 0 0
Water Extractor 6 k,F 0 ' :. 0 s" s , 0 0 0
Water Closet - Toilet 6 - '; ,
7i"` 0 . ; Mx
, ''� � 0 : �,L
, :1::� 4 , 6 1 6
Urinal 6 :� . � 0 ,.� 0 ., .; t;..
Previous EDU Count ,- - ' 4 }: , 0 0
Capped EDU Credit , ' . z` , ' 0
TOTALS 0 0 • 1 2 3 14 2 12
Current Fixture Value 12 divided by 16 = 0.8 Current EDU 1 EDU = $ 2,500
Previous Fixture Value 0 divided by 16 = 0.0 Previous EDU
Change 12 divided by 16 = 0.8 over (under) $ 2,000.00
Enter EDU Change Here t " 018;` ; £
Notes:
Signature:'�7i, fF,0r Date: /4: dc/
Building Division
Note: The property owner shall retain the ORIGINAL sewer tally record. If credits exist, this document will serve as a voucher
hich must be submitted to the City of Tigard Building Division to redeem credits towards future system development charges.
i:\Building\Sewer Tally \SewerTallySheet.xls 7/1/04